Strategic Marketing Financial Services, LLC

QUOTE REQUEST
State of residence		purpose of insurance:
Client Name		Income protection, estate preservation, business, mortgage protection funeral, other
E-mail Address / Contact number		Carrier preference: If so, which ones?
Gender	Male Female	Family HX: any heart disease or cancer in parents or sibilings before age 70? If so, what age? Is relative still living?
Date of birth
Tobacco User (Y) or (N)	YES NO	Health issues: If any, please list exact diagnosis along with date of onset, treatments, and date treatment ended or if still ongoing.
If no, any history and last time used?
If, yes, what types of products and how often? cigarettes, cigars, pipe, chewing tobacco		Medication:If any, please list names and dosages
Other		Driving history: any tickets, dui, reckless driving, revocation of license etc.
type of coverage:
level term		Travel plans: list all cities and countries (outside US) in the next year.
return of premium term		Any hazardous activities: E.G. rocking climbing, ski diving, bungy jumping etc.
Universal		History of substance abuse: If so, what types of substances, date treatment ended or ongoing
Whole
Indexed Universal		Comments
Final Expense
If term, how many years?

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