Fidelity Insurance Company Home dots Email dots Site Map
Spokane

Life Quote

 
Birth Date

Gender
 Male Female
EVER used or smoked tobacco, nicotine or related products? Yes No
 








State

Face Amount

Product Type

Health Risk

Physique
 
Please Note: Comparisons and quotes are intended for guidance and educational purposes only. The consumer is urged to seek the advice of independent life insurance advisors. E.&.O.E. WinQuote™ is a trademark of CompuOffice Software Inc.
 


 
Extended Information: Quotation Questionaire
Please Note: The Qualification Analysis is intended to fine tune the comparisons and quotations, and to better reflect what you may actually qualify for. It should be noted, however, that it is for guideline purposes only. The underwriting criteria and practices of each insurer and the wordings of each respective policy contract govern. E.&.O.E.
What is your blood pressure?

Have you ever received treatment or medication for high blood pressure?

What are your cholesterol figures?

Have you ever received treatment or medication for cholesterol?

Do you have any history of or been treated for alcohol abuse?

Do you have any history of or been treated for drug or substance abuse?

Have you ever been convicted of a minor moving violation? Yes No

If Yes then when:
Have you ever been convicted of a major moving violation? Yes No

If Yes then when:
If you have ever been convicted of a major moving violation, what was the nature of the violation?

Have any immediate family members (parents, brothers or sisters) suffered from heart disease or heart attack? Yes No

If Yes then when:

Parent(s)    

Sibling(s)

Have any immediate family members (parents, brothers or sisters) suffered from Cerebrovascular Disease? Yes No

If Yes then when:

Parent(s)

Sibling(s)

Have any immediate family members (parents, brothers or sisters) suffered from Cancer? Yes No

If Yes then when:

Parent(s)

Sibling(s)

Have any immediate family members (parents, brothers or sisters) suffered from Diabetes? Yes No

If Yes then when:

Parent(s)

Sibling(s)

Have any immediate family members (parents, brothers or sisters) suffered from other critical illness? Yes No

If Yes then when:

Parent(s)

Sibling(s)