Impaired Risk Proposal Request

HIGH RISK LIFE INSURANCE QUOTE

Please provide the following information regarding the applicant:

Applicant's Name

Applicant's Street Address

Street Address (Cont)

City

State

Zip/Postal Code

Phone

Best Time to Call

E-mail Address

Applicant's Date of Birth

Applicant's Sex

Male Female

Applicant's Height

Applicant's Weight

Applicant's Tobacco Use

None Cigarettes Cigars Pipe Chew

Applicant's family history:

Age If Living

State of Health or

Cause of Death

Age at Death

Father

Mother

Brothers & Sisters

Current health plan:

Plan type

Face amount for current plan

Amount of insurance in force

Medical impairment summary:

Explain current

medical impairments

Actions by other insurance companies:

Insurance company providing quote
Was applicant declined?	Yes No
Rated
Reason for decline
Plan name
Plan amount
Please enter any other comments or questions for the quote.