34 Woodstock Road, Roswell GA 30075                                 770/594-2200  

If you would like us to quote your group or if you would like to provide us with your household demographics, please click on the census below to give us the information we need.  You can email us the census and let us know if you're looking for LIFE INSURANCE, MEDICAL INSURANCE, DENTAL INSURANCE, LONG TERM CARE, OR DISABILITY.  Let us know what level of life insurance you wish A GROUP PLAN 

Census        

PRE-QUOTE/PRE-UNDERWRITING LIFE AND DISABILITY INSURANCE QUESTIONNAIRE

1. Name:___________________________________________________________
2. Occupation:_______________________________________________________
3. If you are applying for Disability, what are your current earnings: $___________
4. Height / Weight: _______________ ‘ _________________”________________#
5. How many times per week do you exercise? _____________________________
6. What form of exercise do you practice? _________________________________
7. Are you seeking personal or business life insurance? ________________________
8. Are you currently being treated for any serious illness (heart, other organ, diabetes, cancer, mental disorder, etc.)? ___________________________________________________________           ___________________________________________________________          ___________________________________________________________
9. Are you currently taking any medications? ___________________________________________________________           ___________________________________________________________           ___________________________________________________________
10. Do you have any scheduled health procedure or surgery? ___________________________________________________________            ___________________________________________________________
11. Do you have any back or knee ailments? ____________________________
12. Have you seen a Chiropractor in past five years? ______________________
13. If YES, why? ______________________________________________________
14. Do you plan to replace your current life/disability insurance?  YES / NO
15. What amount of life insurance do you currently have that you intend to retain?              $__________________________________________________________
16. Do you have any other health issue not mentioned above? ____________________________________________________________         ___________________________________________________________            ___________________________________________________________
17. Family History: Parent Living: ________________________  Age: ________

Parent Living: ____________________  Age: _________ 

Parent Deceased: ____________ Age at Death: _______ Reason for Death: ______________________           

Parent Deceased: ____________ Age at Death:_______    Reason for Death: ______________________

                             Siblings living: ____________________  Age: ________      

                             Sibling living:   ____________________  Age: _______     

Sibling Deceased: ___________ Age at Death:________

Reason for Death: ______________________           

Sibling  Deceased: __________ Age at Death: ________

Reason for Death: ______________________