DAVE KELLY INSURANCE

" Save with Dave "
11141 Tampa Ave
PO Box 7061
Northridge, CA 91327-7061

Get a quote for term life insurance

Today's Date:

Last Name:

First Name:

Email:

*Age:

*Height:

*Weight:

*Sex:

Female Male

*Have you ever used any form of tobacco or other nicotine products?:

Yes No

If yes, please list the type, frequency, and amount of tobacco used:

If you quit, state when in above box..

Your date of birth:

Month date, year (example): March 15, 1981

Desired term length for insurance coverage:

10,15, 20, 25, 30 or any # of years you choose.

Desired face amount:

$250,000 or $2,500,000 or any amount you choose.

If you checked any of the above selections, or if you had any serious diseases or injuries, please give details:

Blood Pressure Level and date last checked (if known):

Cholesterol Level and date last checked (if known):

Are you currently using any medications? If so, what is their purpose? Please give names and dosages:

Have you been hospitalized in the last 5 years? If so, what for?:

Father's age and state of health if living:

Or age at death and cause of death.

Mother's age and state of health if living:

Or age at death and cause of death..

Siblings' age if living and state of health:

Or age at death and cause of death.

If you have recently been declined coverage, please state the reason.:

If you plan to travel or reside outside the USA or Canada within the next 2 years, please state where.:

Please give details if you participate in any high-risk activities such as aircraft pilot, SCUBA diving, spelunking, rock climbing, racing, etc.:

You may reach me at 818-527-5007; what is your direct phone number?:

Thank you for answering the questions. I will shop many companies for your specific needs quote.

Submit Your Message:

CA insurance license 0G26350

" Save with Dave "
11141 Tampa Ave
PO Box 7061
Northridge, CA 91327-7061