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TRI-STAR LIFE INSURANCE QUOTE FORM
Tell Us About You
All information is kept in strict confidence.
How did you find us*Let Us Save You Money
Email Address*
Your First Name:*
Your Last Name:*
Home Address*
City:*
State:*
Zip Code:*
Best Phone Number*include area code
Your Date of Birth*
Which Life Plan?*
How much life insurance do you need?*100k/300k/500k/1 mil
Tobacco use?*
Non-Tobacco user
Yes, Tobacco user
Height / Weight*ex: 5`10, 180
Describe any health issues?if none, leave blank
Occupation:*
Employer Phone:*
Your Spouse`s Information
Your First Name:
Your Last Name:
Your Date of Birth
Tobacco use?
Non-Tobacco user
Yes, Tobacco user
How much life insurance do you need?*100k/300k/500k/1 mil
Height / Weightex: 5`10, 180
Describe any health issues?if none, leave blank
Occupation:
Employer Phone:
Children Term Rider
Do you need a CTR for kids under 18
Yes
No
20,000 rider
Medical History Main Insured
Heart Circulation Problems/HBP/Stroke:*
No
Yes
Lung Disorder/Asthma:*
No
Yes
Cancer (incl. skin):*
Yes
No
Diabetes: diet control/oral meds/insulin:*
Yes
No
AIDS/ARC:*
Yes
No
Mental/Nervous/ADD:*
Yes
No
Alcohol/Drug Disorder:*
Yes
No
Medical expense of $5000+ in the last yr:*
Yes
No
Pregnancy/Disability:*
Yes
No
Hazardous Hobbies (ie flying, skydiving):*
Yes
No
Mountain-climbing / scuba diving / Other:*
Yes
No
Please expand on the YES answers above:
List any current medications:*No Meds enter None
Medical History (Spouse)
Heart Circulation Problems/HBP/Stroke:
No
Yes
Lung Disorder/Asthma:
No
Yes
Cancer (incl. skin):
Yes
No
Diabetes: diet control/oral meds/insulin:
Yes
No
AIDS/ARC:
Yes
No
Mental/Nervous/ADD:
Yes
No
Alcohol/Drug Disorder:
Yes
No
Medical expense of $5000+ in the last yr:
Yes
No
Pregnancy/Disability:
Yes
No
Hazardous Hobbies (ie flying, skydiving):
Yes
No
Mountain-climbing / scuba diving / Other:
Yes
No
Please expand on the YES answers above:
List any current medications:No Meds enter None
How else may we be of help?
Please add any additional comments or questions
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