General  Supplemental Questionnaire for Life Insurance

Please complete the following information:

State of Residence
Name
Address
City/Zip
Home Phone
Work Phone
Fax
Email
Height/Weight
Tobacco Use Yes  No
Life Insurance Amount     UL/WL     Term
Type of illness
Month and Year Diagnosed (mm/dd/yy)
Type of treatment Surgery month/year (mm/yy)
Medications--Please list types, amounts, frequency

 
Last time you visited a physician about this  (mm/yy) 
Cholesterol Reading
Blood Pressure Reading
Do you exercise 3 or more times per week Yes  No
List any other illness or impairment
List All medications currently being taken
Has any parent or sibling died before age 65 other than by accident Yes-- Who & cause  No
Last Life Insurance applied for and result
Other Comments
 

Either Submit or printout form and fax to 620-254-7938, Attn: Special Life Underwriting 

Products and services offered by the Eck Agency may not be available in all states. This information shall not constitute an offer in any state in which a product or company is not properly registered or licensed. The Eck Agency generally offers and sells its products and services only in the states of Kansas & Oklahoma . This information shall not constitute an offer in any foreign country.  All quotes are subject to underwriting and may not be available in all states.

Copyright © 2000 Eck Agency, Inc. All rights reserved.
Revised: April 29, 2008