Combined Life & Long-Term Care Request for Quote

Combined Life & Long Term Care
Request for Quote

Please read our Customer Privacy Statement

Type of Life Insurance Requested

General Information

Name:

Address:


City		State		Zip Code

E-mail Address:

Best time to contact you:		Phone Number		Alternate Number

Applicant

Gender:

Marital Status:

Age:

Smoker?

		Height		Weight
Applicant				lbs.

Do you have life insurance at this time?

What type?

What is the face amount?

Do you currently own a long-term care policy?

Benefits period length?

Daily Dollar Benefit?

Increased Cost of Living or Inflation Adjustment?

How are your current policies issued?

Plan Benefits

Duration of Benefits Period Wanted

Daily Dollar Benefit Paid to the Insured

Life Insurance Face Amount Considered

Abbreviated Medical History

Current medical conditions or treatment:

Past medical illnesses that may be regarded significant:

Current prescription medications

Hospitalizations within the past 5 years not otherwise already reviewed:

Has any parent, brother, or sister had diabetes, heart disease, or high blood pressure?

Do you participate in hazardous sports such as motorized racing, scuba diving, or parachuting?

Please review your entries for correctness before clicking the button labeled "Send!".

You can also contact us at:

Internet Insurance Agency, Inc.
6656 NW 43rd Terrace
Boca Raton, Florida 33496

(866) 988-6858 Toll-Free
(561) 999-0229

For additional information, Contact us directly at:
Info@InternetInsuranceInc.com