Professionals Choice Insurance Questionnaire

Please send me more information about:

Life Insurance Long-Term Care
Healthcare Service Discounts/Pharmacy Discounts

Information:

Member ID:

Name:

Smoker Non-Smoker

Date Of Birth (DOB)

Year

Gender:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Fax:

Email:

Spouse's Name

Smoker Non-Smoker

DOB

Year

Child's Name

Smoker Non-Smoker

DOB

Year

Child's Name

Smoker Non-Smoker

DOB

Year

Child's Name

Smoker Non-Smoker

DOB

Year

Child's Name

Smoker Non-Smoker

DOB

Year

Face Amount - Term $ (example: $25,000 for 20 year term)

Have you EVER had or been diagnosed as having any of the following conditions? Check all that apply

Alzheimer's Disease
Amputation due to disease
Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease)
Chronic Hepatitis
Cirrhosis of the liver
Dementia
Hydrocephalus
Multiple Sclerosis
Multiple strokes, CVAs or TIAs

Muscular Dystrophy
Myasthena Gravis
Organic Brain Syndrome
Paraplegia or Quadraplegia
Parkinson's Disease
Polymyositis
Scleroderma
Senility
Other (specify):

Quote provided based on information on the above form. Standard Rates apply -- unless under Preferred Rates.

Phone: 800-480-3747
Fax: 417-447-1148