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Life Insurance 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)

Check All Options To Be Illustrated

Amounts
50,000	250,000	2,000,000
100,000	500,000	5,000,000
200,000	1,000,000	Other
Number of Years to be Covered
10 yrs	25 yrs	age 85
15 yrs	30 yrs	age 100
20 yrs	age 65	Other

Policy Types
Term Life	Equity Indexed Universal Life
Return of Premium Term	Permanent (Cash Value) Life
Universal Life	Final Expense
Variable Universal Life	No Physical Required, Apply Online
Other

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 provide details:

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

Additional Comments

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
IRA Rollovers	Disability Income	Annuities
Medical	Financial Services	Retirement
Group	Long Term Care	Business P & C

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.