Life and Health Info Request Form

LIFE & HEALTH INSURANCE QUOTE

Instructions
Fill out the form below as completely as possible. An Empower agent will then contact you with the lowest possible price based on the information you provide.
Or if you feel more comfortable calling, you can find an agent at 1-800-901-2406.

Insured Information
Spouse Info
Children
Coverage Needed
Medical History

Insured Information

Which type of Insurance do you need?
First Name:	Last Name:	E-mail Address:
Street Address:	Apartment/Suite #:	City:	State:	Zip:
Home Phone:	Work Phone: ext.	Fax Number:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Occupation:	Employer's Phone:	Employer's Fax:
Do you use other tobacco products?	Are you a smoker?

CONTINUE >

Spouse Information

Will your spouse need coverage?

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Occupation:	Employer's Phone:	Employer's Fax:
Smoker?	Uses other tobacco products?	Non-smoker?

Children Information

How many of your children will need coverage?

Child #1

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #2

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #3

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #4

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #5

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #6

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #7

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #8

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #9

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Child #10

First Name:	Last Name:
Sex:	Date of Birth:	Age:
Height: ft. in.	Weight: lbs.
Smoker?	Uses other tobacco products?	Non-Smoker?

Coverage Needed

(Check all that apply)

Life	Health	Short-Term Health
Dental	Disability	Long-Term Care

Heart Circulation Problems/HBP/Stroke	Lung disorder/Asthma	Cancer (inc. skin)
Diabetes: diet control/oral meds/insulin	AIDS/ARC	Mental/Nervous/A.D.D
Alcohol/Drug disorder	Medical expense of $5000+ in the last year	Pregnancy/Disability
Hazardous hobbies (ie flying, skydiving)	Auto/Boat/Motorcycle/Dirt-bike racing	Mountain-climbing/Scuba Diving/Other
List any current medications	Please verify that all the information you have entered is correct. Then click the Submit Quote Info button to send us your request for a quote