Desanctis Insurance Specialists LLC

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Life Insurance

TERM LIFE INSURANCE, UNIVERSAL & WHOLE LIFE INSURANCE, FINAL EXPENSE INSURANCE

Have you been declined and labeled uninsurable by other life insurance companies?  We have a solution.  Apply now for a free quote by completing the form below.

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Life Insurance Free Quotation Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

General Information
* Name:
Address:
City:
* State:
  * Zip:
Phone:
Best Time To Call:
AM   PM
* E-mail Address:

Information About You and or Your Spouse
Please enter information below for all to be covered.
SELF SPOUSE
Name:
Date of Birth:
Sex:
Male  Female Male   Female
Marital Status:
Married   Single Married   Single
Occupation:
Height:
ft . in. ft . in.
Weight:
bs. lbs. .
Smoker:
Yes   No Yes   No

Have you had any of the following health conditions:

 

Current Household Income:

Heart
Cancer
Diabetes
HBP

Heart
Cancer
Diabetes
HBP

 


Medical Background
Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)

  Past 60 months: Yes   No
  Past 36 months: Yes   No

Have you ever been rated or declined for life insurance?   Yes   No

If so, why?

Have you ever been treated for high blood pressure or cholesterol?   Yes   No
Has any member of your family (parent or sibling) died from coronary artery disease prior to age 60?   Yes   No
Is there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60?   Yes   No
Are you currently taking or have you been advised to take any prescription medications?   Yes   No

If so, what type and why?


Additional Comments or Questions

 
 

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