The Hart Smith Company: Life Insurance Quotation Form

LIFE INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

The Hart Smith Company is licensed in the state of Georgia. No solicitation of insurance is being made outside of this state.

Personal Information
Your name
E-Mail address
Phone numbers	Daytime
	Evening
	Fax
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-Mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address City State, Zip
Occupation
Social security number
Date of Birth
Sex
Height & Weight

General Questions
Are you a citizen of the United States?	Yes No
Have you lived outside the United States during the last 3 years?	Yes No
Do you plan to leave the United States for travel or residence during the next 3 years?	Yes No
Please list the foreign countries that you are planning to visit / reside
Do you currently work in a hazardous occupation?	Yes No
Do you participate in any risky outdoor activities?	Yes No
Do you fly as a pilot, co-pilot or crewmember of an aircraft?	Yes No
Are you an active member of the military or military reserve?	Yes No
Have you received 3 or more moving violations or had your driver's license suspended / revoked in the past 5 years?	Yes No
Have you been found guilty of reckless driving or driving under the influence (DUI / DWI)?	Yes No
When was the last time that you used any type of tobacco product or nicotine substitute?
Is there any family history of cardiovascular disease before the age of 60?	Yes No
Have you had any health symptoms or been treated for any of the conditions listed below?	Yes No
If yes, please check those below which apply

AIDS & AIDS related	Epilepsy	Liver disease	Psychiatric disorders
Alcoholism	Fatigue disorders	Lupus	Rheumatoid arthritis
Alzheimer's	Heart Disease / Bypass surgery	Lymphoma	Seizure disorders
Asthma	High Blood pressure	Manic depression	Spinal disc disorders
Breast cancer	HIV	Melanoma	Stroke
Chronic bronchitis	Infertility	Multiple sclerosis	Substance abuse
COPD	Joint replacement	Muscular distrophy	TIA
Diabetes	Kidney stones	Other demyelinating disorders	Ulcerative colitis
Emphysema	Leukemia	Peripheral vascular disease	Uterine disorders

Do you have cancer?	Yes No
If yes, specify cancer details here:

General Information
Coverage amount?
Desired term period?
Quote requested within	24 hrs 48 hrs 72 hrs
Do you want an umbrella quote?	Yes No