Gralak Insurance Agency - Term Life Form

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Term Life Form

Name *

House Address

City

State

Zip Code

Home Phone *

Work Phone

Fax

E-mail Address: *

Present Insurance Carrier

Date of Birth (mm/dd/yyyy)

Have you used any nicotine products in the last 6 years?

Yes
No

If yes, please give details - type of product (cigarette, cigar, chew, pipe), amount used, length of use, last used

What is your weight?

What is your height?

Are you on any medications and if so, why are you taking them?

Have you ever had or do you now have, any of the following

Cancer
HIV
Hepatitis
Heart Problems
Stroke
Mental Health Problems
Alcoholism
DUI
Diabetes
Other Serious Disease

If Other Serious Disease, please explain

Please provide details - date of diagnosis, treatment, last date of treatment, etc.

Has any of your immediate family (siblings, mother, father) passed away prior to age 60?

Yes
No

If so, was it due to cancer, heart disease, or stroke?

Yes
No

Has any living member of your family had cancer, heart problems, stroke or diabetes prior to age 60?

Yes
No

Have you ever been rated or declined for insurance?

Yes
No

If so, please provide details

Do you participate in any special activities (aviation, scuba, rock climbing, motorcycle racing, etc.) recently traveled to a foreign country or have plans to do so?

Yes
No

How many moving violations do you have in the past three years?

Please provide details

Verification Code: Visual Verification Image

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Gralak Insurance Agency | 6826 W. Archer Avenue | Chicago, IL | 60638 | 773-284-7650