Hertel Insurors Group, L.L.P.
“Reducing your total cost of risk”
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Individual Life Insurance Form
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Your Information
Named Insured
Email Address
Phone Number
Sex:
Male
Female
Date of Birth
Face Amount
Term Length (10, 20, 30 year)
Occupation
Income
Check if interested:
Whole Life
Term Life
Guaranteed Life
Tobacco Usage
In the last 5 years:
Yes
No
If yes, type?
Cigarette
Cigar
Pipe
Chew
Dip
Nicotine Gum/Patch
Date Nicotine Last Used?
Health History
Height
Weight
Any History of:
Elevated Cholesterol?
Cancer?
Elevated Blood Pressure?
Stroke?
Heart Disease?
Diabetes?
Other Than US Resident?
Felony Convictions?
Active Military Duty?
Private Pilot?
Scuba Diving?
Other Hazardous Sports?
Alcohol/drug abuse/DUI/or more than 2 moving violations in past 3 years?
Details to any YES answers above — medical conditions and medications. Include information within the past 5 years for conditions, treatments, and hospitalizations. If taking any medications, please provide name, dosage, and date treatment began:
Family History
Relationship
Current Age
If deceased, age/cause of death
If living, describe current health conditions. If diagnosed with Coronary disease or cancer, please state age of diagnosis:
Add another family member
Your Information
Financial Advisor Name
Phone Number
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