John J. Prudente Agency

First Name:

Last Name:

Address:

City:

State

ZIP:

Daytime Phone:

Evening Phone:

Fax Number:

E-mail Address:

Best contact time:

Gender:

Date of birth:

Height:

Weight:

pounds

How much life insurance would you like us to quote?

Not Sure? Please see our easy to use online chart Roughing Out Your Life Insurance Needs to help determine how much life insurance is right for you and your family.

What type of life insurance are you looking for?

If other, please describe the type of coverage you are looking for:

The coverage to be quoted will likely be:
new coverage (I have none now)
additional coverage
replacement of existing coverage

Tobacco/Nicotine Use:

Do you take any prescription medications? Yes No

If yes, please state name of medication, dosage (if known), and the condition it is treating:

Do you have any health conditions? Yes No

If yes, please explain:

Have you ever been advised or treated for any of the following?

AIDS
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Cholesterol
COPD
Depression
Diabetes

Heart Disease
Hypertension
Kidney or Liver Disease
Mental Illness
Stroke
Ulcerative Colitis or Ileitis
Vascular Disease
Other
None of the Above

If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status:

Are you a private pilot or student pilot? Yes No

If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.):

Do you engage in a hazardous avocation or occupation, i.e. scuba diving, sky diving, rock climbing, or motorized racing? Yes No

If yes, please explain in detail:

Have you been convicted of drunk driving, or had your driver's license suspended or revoked in the past 10 years? Yes No

If yes, please explain in detail:

Have you been convicted of 2 or more moving violations in the past 3 years? Yes No

If yes, please explain in detail:

Have you ever been convicted of, or are you awaiting trial for a felony? Yes No

If yes, please explain dates, charges, and details:

In the past 5 years, have you filed for bankruptcy? Yes No

If yes, please provide details or date of discharge:

Did any of your parents or siblings have cardiovascular disease or cancer, prior to age 60? Yes No

If yes, please explain including age of onset, diagnosis, and death (if applicable):

Are you a United States citizen:

Yes, I am a United States citizen.
No, but I am a permanent resident with a green card.
No, I am not a citizen, nor do I have a green card.
If no, what country?
If you are not a U.S. citizen your options are limited, but some companies may provide coverage.

Any other questions or comments?

Life Insurance Quote