Tomei Insurance Agency - Health Quote

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Health Insurance

Medical/Health Questionnaire

For the Fastest and most accurate quote, please provide as much information as possible. This information will be kept confidential and will be used for quote purposes ONLY!

Name:
Street Address:
	City: State: ZIP:
Email:
Phone:
Please Contact me by:	When (Time)

Personal Information

Name :
Date of Birth :
Gender :	Male	Male	Male	Male	Male
Gender :	Female	Female	Female	Female	Female
Tobacco Use :	Y N	Y N	Y N	Y N	Y N
Height:	ft. in.	ft. in.	ft. in.	ft. in.	ft. in.
Weight:	lbs	lbs	lbs	lbs	lbs

Are there any past or current health problems? If yes, please provide details:

Is anyone currently taking any medications? If yes, please list name and provide details:

Has anyone ever been declined for life or health insurance? If yes, please list name and provide details:

Additional Comments, Children, ETC...

Please give any additional comments, questions or concerns

I/We would like information on the following:

Auto	529 College Savings	IRA
Home	Executive Benefits	401-k
Life	Disability Income	Annuities
Medical	Financial Services	Retirement
Group	Long Term Care	Business P & C
IRA, 401-k, 403-B, etc.. Rollovers & Strategies

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

Enter the security code you see above. Code is NOT case sensitive. *

Savings • Service • Security

Tomei Insurance Agency, 223 N. Riverside Drive (Rt. 21 @ Wash St.) , Gurnee, IL 60031
Toll Free 877-336-8595, Local 847-336-8595, Fax 847-336-6598, Mail@TomeiInsurance.com, www.TomeiInsurance.com

*Securities offered through Investment Planners Inc.
Member FINRA/SIPC
226 W. Eldorado St.,
Decatur IL 62525
Tomei Insurance Agency is not affiliated with Investment Planners Inc.