Lee Insurance Concepts

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PERSONAL LIFE INSURANCE

Please fill out the information in the following form to get a quote for life insurance.

Would you like to request an initial quote or apply for a policy?
General Information
First Name			Middle Initial
Last Name			Suffix
Gender			Height	ft. in.
Weight	lbs.		Date of Birth
Place of Birth: City, ST	,		Place of Birth: Country
Social Security Number			Occupation
Annual Income			Needed For
Insurance Amount			Premium Mode
Address			Suite/Apt
City			State
Zip
Phone			Best day to contact
Your time zone			Best time to contact
Email			Smoker?	Yes No

Ownership Information
The Owner, who is usually the Insured, controls the policy. Will the Insured be the Owner of this policy?				Yes No
Primary Beneficiary Information
	Percentage	Type	Name	Relationship
Beneficiary 1
Beneficiary 2
Beneficiary 3
Beneficiary 4

Health Information
Within the past 90 days, has the Proposed Insured been admitted to, or been advised by a medical professional to be admitted to, a hospital?	Yes No
In the past two years has the Proposed Insured been treated for: heart attack, stroke, coronary artery disease, cancer, alcohol, or drugs by a medical professional?	Yes No
In the past two years, has the Proposed Insured been tested positive for exposure to the HIV Infection or been diagnosed as having ARC or AIDS caused by the AIDS infection or other sickness or condition derived from such infection?	Yes No
Please provide complete details to any yes answer above. Be sure to include dates of treatment, diagnosis and name/address of treating physician(s).

Existing Policy Information
Do you have any other existing insurance policies or annuity contracts with this or any other company? (in force or applied for)	Yes No
To the best of the applicant's knowledge, will the policy applied for replace any existing life insurance policy or annuity, or is any part of the premium to be paid by policy loan, or cash value on insurance presently in force?	Yes No
Does the applicant have any existing life insurance policies or annuity contracts with this or any other company?	Yes No
To the best of your knowledge, will this insurance replace or change any existing life insurance or annuity?	Yes No

Existing Policy	Replace?	Type	Company	Total Amount/Premium
Policy 1	Yes No			/
Policy 2	Yes No			/
Policy 3	Yes No			/
Policy 4	Yes No			/

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