LIFE INSURANCE QUOTE

Oswald Insurance will provide a quotation based on the information provide us. The more precise, the better. Information submitted will be confidential.  

Fields marked with an asterisk * are required.

CONTACT INFORMATION
Your First Name:  *
How would you prefer to be contacted regarding your quote? Email Phone Fax*
Email address: 
Fax Number:
Phone Number:
Best time to call:
Morning Afternoon Evening
Your Age: 
Sex:
Height:
Weight:

GENERAL QUESTIONS
Are you a citizen of the United States? Yes No
Do you plan to work or travel outside the USA or Canada for more than 30 days in the next 2 years? Yes No
Do you participate in any dangerous outdoor activities? Yes No
Do you fly as a pilot, co-pilot or crewmember of an aircraft? Yes No
Are you a member of the military? Yes No
Have you received three or more moving violations or had your driver's license suspended/revoked in the past 5 years? Yes No
Have you been found guilty of reckless driving or driving under the influence (DUI/DWI) Yes No
Do you use nicotine in any form? Yes No
Is there any family history of cardiovascular disease before the age of 60? Yes No
Have you had any health symptoms or been treated for any of the conditions listed below? Yes No

If Yes, please check those below which apply:
AIDS & AIDS related Epilepsy Lupus Rheumatoid arthritis
Alcoholism Fatigue disorders Lymphoma Seizure disorders
Alzheimer's Heart Disease/Bypass Manic depression Spinal disc disorders
Asthma High blood pressure Melanoma Stroke
Breast cancer HIV Multiple sclerosis Substance abuse
Cancer Infertility Muscular dystrophy TIA
Chronic bronchitis Joint replacement Other demyelinating disorders Ulcerative colitis
COPD Kidney stones Peripheral vascular disease Uterine disorders
Diabetes Liver disease Psychiatric  
please give details on any conditions you have listed above
COVERAGE INFORMATION
Coverage amount?

 
Desired term period?

 
 

 

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