Title - Portland, Ct Insurance Services, Health, Home, Life, Business, Auto

Substandard Life Impaired Risk Quote Request

You must fill in the form as complete and accurately as possible for the quote requested.The information will be e-mailed to our offices and reviewed in order to expedite your request. Your information is confidential and will be used only by our company for the purpose of this quote

Fields marked with a Red asterisk * are required. Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information
*Name
Address:
City:	State Zip
Phone:	*Work
	*Home
	Fax
*Email Address:

Quote Information
Date of Birth:	mm/dd/yyyy
Gender:	Male Female
Have you used tobacco?:	Yes No
If yes specify type, date of last use:	Cigarette date mm/yy Cigar date mm/yy Pipe date mm/yy Chewing Tobacco date mm/yy
Height and Weight	(ex: 5' 8")
	(ex:150 lbs)
Are you a pilot? (If yes complete aviation Section in the additional categories below)	Yes No
Amount Needed
Policy type:	Term Permanent Second to Die
Desired Premium Range

General Medical
Describe your Health/Medical impairment or Special risk
Date Diagnosed
Medications (include dosage)
Cholesterol:	Ratio:
Blood Pressure
Types and dates of surgery or hospital treatments:
Family History ("Father", "Mother", "Siblings") Give any reasons for deaths prior to age 60:
Since diagnosis, list any lifestyle changes: (exercise program, stopped smoking, etc.
	Note: If additional catergories apply to you below you must complete forms and submit seperately.
Please click on the *"Submit Request"* button to send us your quote request.

Complete and submit additional catergories that apply. Alchoholism/Drug abuse
Aviation
Build
Cancer
Cardiovascular Impairments
Chronic Pulmonary (Lung) Disease
Depression/Anxiety Disorder
Diabetes
Elevated Liver/Enzyme
Financial Justification
Hazardous Activities
Hypertension
Moral Hazzard
Sleep Apnea

Alcohol
How long since you have consumed alcohol?:
Are you a member of AA or a similar organization?(Give Details; Dates, How often do you attend meetings?:
Current Family Situation:
Current Occupational Situation:
Has blood profile (including liver function tests, and "Alcohol Marker") been performed by a Physician within last 12 months?	Yes No

Drug Abuse
Name of drug used:
Date of last use
Current Family Situation:
Current Occupational Situation:
Please click on the *"Submit Request"* button to send us your quote request.

Aviaition
Total Flight Hours Logged:
Make of aircraft flown:
Type of certification:
Year Issued:
Do you have an instrument flight rating(IFR)?	Yes No
Hours flown in the last 12 months?
Estimated Hours for the next 12 months:
Personal Use%
Business use %
Type of business use:
Do you fly a military aircraft?	Yes No
If yes type of military aircraft?:
Estimsted hours per year:
Purpose and Frequency of military travel:
Please click on the *"Submit Request"* button to send us your quote request.

Build
Highest weight ever:
Highest weighgt in the last ten years?:
Approximate weight of immediate family members (mother, father, siblings):
Has an immediate relative (mother, father, siblings) died prior to age 60 of Heart Disease, Diabetes, or Cancer?:	Yes No
If yes explain
Amount of weight loss in the last 12 minths:
Have you ever had an EKG or any other Cardiac related testing performed in the last 10 years?:	Yes No
If yes type of test performed and when:
Were there any noted abnormalities?	Yes No
If yes explain:
What efforts are being made to control your weight? (exerscise, diet, meds, etc..):
Please click on the *"Submit Request"* button to send us your quote request.

Cancer
Cancer
Date Cancer diagnosed:
Type(e.g. adenocarcinoma melanoma, etc.)
Location (e.g. prostate, liver ect.)
Stage, Grade or Clarcks level:
Any Chemotherapy or radiation treatment?	Yes No
If yes, date of last treatment and total number of treatments:
Any other treatments?	Yes No
If yes provide detail:
Any Mestastasis? (spreading to other parts of the body)	Yes No
If yes provide detail:
Any Lymph Node Invlvement?	Yes No
If yes provide detail:
Any recurrences or relapses?	Yes No
Any family history of cancer?	Yes No
If yes date of last treatment and total number of treatments:
If prostate Cancer, Provide Results and Dates of Most Recent PSA Readings:
Please click on the *"Submit Request"* button to send us your quote request.

Cardiovascular
Date of Diagnosis:
Type of impairment (Heart Attack, Bypass, Angioplasty, Heart Murmer, etc.):
Type of surgery or treatment (if Bypass, #of vessels ivolved):
Is there any history of chesty pain? (include dates):
Current medications (include dosages):
What tests were performed? (treadmill, EKG, Echocardiogram etc.):
What were the results?:
Please give details regarding: 1)blood pressure 2)cholesterol 3)build 4) family history 5)diabetes
Describe any lifestyle changes made since the Cardiac event: exercise diet etc.):
Family History (give "Reasons" for any deaths prior to age 65: include father mother, siblings):
Please click on the *"Submit Request"* button to send us your quote request.

Chronic Pulmonary Lung Disease
Type of lung disease: (Asthma, Emphysema, COPD, etc...):
Have you ever been hospitalized for this condition (details):	Yes No
List current medications:
Has a Pulmonary function test been performed?: Date and results of PFT test:	Yes No
Has a chest X-ray been performed?: If Yes, explain:	Yes No
Do you have any restrictions on day-to-day activities? If Yes, give details:	Yes No
How is the impairment treated? (medication, breathing machine, etc...):
Please click on the *"Submit Request"* button to send us your quote request.

Depression/Anxiety Disorder
Diagnosis:
Type of treatment:
Date of last treatment:
Current medication(s):
Any other medical history:
Any suicidal attempts/thoughts?: If Yes how often?:	Yes No
Date of last incident:
Duration that you have been under effective control:
Current family/occupational situation:
Please click on the *"Submit Request"* button to send us your quote request.

Diabetes
Date of diagnosis:
Age at diagnosis:
Type and amount of medication/diet:
Any problems with your eyes, circulation, diabetic coma, protein in urine, etc...?: If 'Yes', date and nature of problem/treatment and outcome:	Yes No
Do you check your blood / urine on a regular basis?:	Yes No
If 'Yes', how often?:
If 'Yes', what are the results?:
Date and result of last fasting Glucose test:
Do you see a doctor regularly?:	Yes No
If 'Yes', what are the results of the doctor's blood work:
Date and result of last Hemoglobin "A1C" test:
Have you had an EKG performed in the last 5 years?:	Yes No
If Yes, were there any abnormalities detected?:	Yes No
If Yes, explain:
Please click on the *"Submit Request"* button to send us your quote request.

Elevated Liver Function Enzyme
Date of last blood test:
Results of GGTP (normal 2-65):
Results of SGOT (normal 2-45):
Have these results been increasing, decreasing, stable or fluctuating?:
Do you currently drink alcohol?:	Yes No
If Yes frequency andquantity of use:
Have you ever had a Liver Biopsy performed?: (Answer only, in severe cases of Liver Enzyme elevations,or if there is a history of Hepatitis)	Yes No
If yes give details:
Are you currently taking any medications?:	Yes No
If Yes, give details:
Please click on the *"Submit Request"* button to send us your quote request.

Financial Justification:
Amount of business insurance on other individuals:
If insurance is for business purposes, what is the percentage of proposed insured ownership?:
Explain details of the sale, and any special circumstances of the case:
Are you replacing another policy?:	Yes No
If Yes, include a 5 year placement history on the case:
Please click on the *"Submit Request"* button to send us your quote request.

Scuba Diving
How deep do you dive?:
Number of dives in the last 12 months:
Number of expected dives in the next 12 months
List all your certifications:
Where do you dive? (include oceans, lakes, oceans etc.):
Sky Diving
Jump altitude?:
Number of jumps in the last 12 months:
Number of expected jumps in the next 12 months
List and describe any certifications:
Racing Cars,Boats, and motorcycles
Type of vehicle and top speed:
If racing, what type of event?:
If racing, what type of fuel is used?:
Classification of vehicle and type of track:
If race is sanctioned by an association please explain:
other
Type of activity:
How often do you participate in this activity?:
How long have you participated in this activity?:
Please click on the *"Submit Request"* button to send us your quote request.

Hypertension
Please give previous high readings and dates of readings:
Current blood pressure reading:
Current medications and how long you've been taking them.:
Have you ever experienced chest pains?:	Yes No
If 'Yes', date of first occurrence:
If 'Yes', date of last occurrence:
Have you had an EKG or any other Cardiac related testing performed in the last 5 years?:	Yes No
If 'Yes' type of tests performed and when:
Were there any noted abnormalities?	Yes No
If 'Yes', explain:
Please click on the *"Submit Request"* button to send us your quote request.

Moral Hazzard
Type of problem (ie; criminal record, lack of applicant candor, criminal associates, convictions, etc...):
Date(s) associated with incidences:
Date of last occurrence:
Have you ever been convicted?:	Yes No
f 'Yes', has time been served, or is case in appeal (explain)?:
Are you currently on parole?:
If 'Yes', when will parole be lifted?:
Describe any lifestyle changes (stable employment, etc.):
Please click on the *"Submit Request"* button to send us your quote request.

Substandard Life Impaired Risk Quote Request

Contact Information

Quote Information

General Medical

Alcohol

Drug Abuse

Aviaition

Build

Cancer

Cardiovascular

Chronic Pulmonary Lung Disease

Depression/Anxiety Disorder

Diabetes

Elevated Liver Function Enzyme

Financial Justification:

Scuba Diving

Hypertension

Moral Hazzard