Your name:
First:
Last:
E-mail address:
Phone numbers:
Daytime:
Evening:
Fax:
How would you prefer to be contacted regarding your quote?
Phone
Fax
Mail
E-mail
If you would prefer to be contacted by phone,
please let us know the best time to call.
AM
PM
Address:
City:
State:
Zip code:
Social Security number:
Occupation:
Date of birth:
Sex:
Height:
Weight:
Are you a citizen of the United States?
Yes
No
Have you lived outside the United States
during the last 3 years?
Yes
No
Do you plan to leave the United States for travel or
residence during the next 3 years?
Yes
No
Please list the foreign countries that you are
planning to visit / reside:
Do you currently work in a hazardous occupation?
Yes
No
Do you participate in any risky outdoor activities?
Yes
No
Do you fly as a pilot, co-pilot
or crewmember of an aircraft?
Yes
No
Are you an active member of the
military or military reserve?
Yes
No
Have you received three or more moving violations or had your driver's license suspended/revoked in the past 5 years?
Yes
No
Have you been found guilty of reckless driving
or driving under the influence (DUI/DWI)?
Yes
No
When was the last time that you used any type of
tobacco product or nicotine substitute?
Select...
Never
1-12 month(s)
13-24 months
25-26 months
37-48 months
49-60 months
Is there any family history of cardiovascular disease
before the age of 60?
Yes
No
Have you had any health symptoms or been treated for any of the conditions listed below?
Yes
No
If Yes, please check those below which apply:
AIDS & AIDS related
Epilepsy
Liver disease
Psychiatric disorders
Alcoholism
Fatigue disorders
Lupus
Rheumatoid arthritis
Alzheimer's
Heart Disease/
Bypass surgery
Lymphoma
Seizure disorders
Asthma
High blood pressure
Manic depression
Spinal disc disorders
Breast cancer
HIV
Melanoma
Stroke
Chronic bronchitis
Infertility
Multiple sclerosis
Substance abuse
COPD
Joint replacement
Muscular dystrophy
TIA
Diabetes
Kidney stones
Other demyelinating disorders
Ulcerative colitis
Emphysema
Leukemia
Peripheral vascular disease
Uterine disorders
Do you have cancer?
Yes
No
If yes, specify cancer details here:
COVERAGE INFORMATION
Coverage amount?
Select...
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$500,000
$750,000
$1,000,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$5,000,000
Desired term period?
Select...
5 Years
10 Years
15 Years
20 Years
25 Years
30 Years
Quote requested within:
24 hrs
48 hrs
72 hrs
120 hrs
Do you want an umbrella quote?
Yes
No
900 N. Herritage St. / P.O. Box 98 Kinston, NC. 28502
Phone: (252) 523-2177 Toll Free: (800) 849-1832 Fax: (252) 523-7217
Kinston Insurance Service Agency, Inc.
E-mail us
with questions
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