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Customer Information
First Name
Last Name
Email
(required)
Phone
Date of Birth
(required)
Gender
(required)
Male
Female
Marital Status
(required)
Single
Married
Divorced
Widowed
Height
4' 0"
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
Weight
Coverage Information
Guaranteed Term
20 Years
25 Years
30 Years
20 Years ROP
25 Years ROP
30 Years ROP
Lifetime Term
Coverage Amount
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1,000,000+
Payment Method
Annually
Semi-Annually
Quarterly
Monthly
History
Have you ever used tobacco products?
Yes
No
Have you ever been treated for high blood pressure?
Yes
No
Have you had your license suspended or revoked, or had more than one ticket or accident in the past 5 years?
Yes
No
Are you currently on parole or probation OR have you ever been convicted of a misdemeanor or felony?
Yes
No
Have you ever had any of the following medical conditions? Alcohol/Drugs, Alzheimer’s Disease, Asthma, Cancer, Crohn’s Disease, Depression, Diabetes, Epilepsy, Emphysema, Heart Disease, Kidney or Liver Disease, Mental Illness, Multiple Sclerosis, Rheumatoid Arthritis, Sleep Apnea, Stroke, Ulcer, Vascular Disease?
Yes
No
Do you participate in any hazardous activities like racing or motor sports, hang gliding, piloting, rock climbing, scuba diving, or sky diving?
Yes
No
Please indicate the total number of family members (parents or siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
0
1
2
3
Additional Information
How did you hear about Peters Insurance Agency?
Referred by Current Client, Friend or Relative
Web Search
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Angie's List
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