Seipel & Seipel Insurance - Life Insurance Application

Seipel & Seipel Insurance Bradenton Florida

Life Insurance Application
Please provide us with ACCURATE & COMPLETE Information, and one of our representatives will get back to as soon as possible.

General Information
Name:
Address:
City:	State: Zip:
County in which you live:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Information About Yourself And Family
Please enter information below for all to be covered.
Date of Birth:
Sex:	M F
Marital Status:	M S
Occupation:
Height:	ft. in.
Weight:	lbs.
Tobacco Use:	Y N
Are both of your parents still alive:	Y N

Personal History
Please list any individual histories on each person to be covered.
1.	Do you have any physical defect? Yes No If yes, please list below.

2.	Have you ever used barbiturates, heroin, cocaine (including crack), marijuana, LSD, PCP, amphetamines, any derivative of these drugs or any other illegal, restricted or controlled substance except as prescribed by a physician? Yes No If yes, please list below.

3.	Have you ever used alcoholic beverages, been advised to limit or cease the use of alcoholic beverages, been counseled or treatment for alcoholic problems or attended any organization for alcohol or related problems? Yes No If yes, please list below.

4.	Have you ever had - convulsions, paralysis, neuritis, nervous breakdown, dizziness, fainting spells, loss of consciousness, migraine or chronic headaches, nervous or mental disorders, high blood pressure, chest pain, palpitations, angina, heart murmur, heart attack, stroke, or other disorder of heart or blood vessels, asthma, tuberculosis, emphysema, bronchitis, sleep apnea or other disorder of the respiratory system? Yes No If yes, please list below.

5.	Have you ever had - shortness of breath, chronic hoarseness or couth, blood spitting, chronic indigestion, ulcer, hernia, colitis, intestinal bleeding, disorder of stomach, gallbladder, liver, digestive or abdominal organs? Yes No If yes, please list below.

6.	Have you ever had - kidney stone, diabetes, sugar, albumin, pus or blood in urine, disorder of kidneys, bladder, genito-urinary organs, rheumatic fever, arthritis, gout, disorder of muscles, bones, joints, or spine, loss of extremity or deformity? Yes No If yes, please list below.

7.	With in the past 10 years, have you - had treatment or observation or been advised to have treatment or observation in any hospital or institution, had x-rays, electrocardiograms, blood studies or other diagnostic test other than an HIV test? Yes No If yes, please list below.

8.	Within the past 5 years have you - been advised to have a surgical operation, been advised to take prescription or non-prescription medication on a daily, weekly, or monthly basis? Yes No If yes, please list below.

9.	Are you or your spouse now pregnant? If yes what is the expected delivery date? Yes No If yes, please list below.

10.	Are you currently being treated or consulted by a physician, psychiatrist or other licensed medical practitioner? Yes No If yes, please list below.

11.	Have any of your immediate family members (parent, brother, or sister) had heart disease, diabetes, cancer, polysystic kidney disease or other familial disease? Yes No If yes, please list below.

Life Coverage's
	Self
Amount of Coverage:	$
Type of Coverage:	Term Whole Universal
Disability Income:	Y N
Long Term Care:	Y N

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.