Tanea Castro Seuros - Formulário para cotação de seguro

Email Address (optional)

Height		Sex
Weight		Date of Birth (MM/DD/YY)

Are you a smoker or do you use any tobacco products?
When was the last time you used a tobacco product?
What type of tobacco product?

Do you have any of the following health problems?

high blood pressure
heart attack or bypass
stroke
overweight
high cholesterol
negative family health history
diabetes
alcohol
drugs
epilepsy
cancer

Do you take any prescription medications?
If yes, list name and dosage:

Have any members of your immediate family had heart disease or cancer before the age of 60? Heart Disease
Cancer

If yes to either, please describe:

FOR LIFE INSURANCE QUOTE REQUESTS ONLY:
Approximate amount of desired coverage (for a quick estimate, multiply your annual income by 7)
What type of Life Insurance/Annuity?
Do you have life insurance?
If yes, what company?
Annual premium?
Date when purchased?
Have you ever been "rated" or declined coverage?

FOR HEALTH INSURANCE ONLY:
Occupation
Estimated monthly gross income
Monthly benefit requested
Number of dependents
Do you have a current plan?
	Type of plan
	Current Insurer
	Monthly Premium

Daytime Phone Number
Evening Phone Number
Best time for an agent to contact you?

When all fields are filled out press SUBMIT.