LIFE / HEALTH

Fill out this online application or feel free to call us! We can fill it out for you!!	LIFE / HEALTH INSURANCE QUOTE We would like to provide you with a free, no-obligation life / health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
There is absolutely no obligation!

General Information

Name:

Address:

City: State: Zip:

Day Phone: Night Phone:

Best Time To Call: AM PM

Email Address:

Information About Yourself And Family

Please enter information below for all to be covered.

Self

Spouse

Child #1

Child #2

Child #3

Name:

Self

Date of
Birth:

Sex:

M F

Marital Status:

M S

Occupation:

Height:

ft. in.

Weight:

lbs.

Have you (they) had any of the following health conditions:

Heart
Cancer
Diabetes
HBP

Self
Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes No If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):

Spouse
Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #1
Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #2
Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #3
Is person to be insured currently on any prescription medications for ongoing health conditions?
Yes No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages
	Self	Spouse	Child #1	Child #2	Child #3
Amount of Coverage:	$	$	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income:	Y N	Y N
Long Term Care:	Y N	Y N

Health Coverages

Self

Spouse

Child #1

Child #2

Child #3

Add Health
Coverage?:

Y N

Please check desired coverages below for your health plan.

High deductible catastrophic plan
No deductible co-pays
Maternity
Mental Health
Chiropractic

Acupuncture
Dental
Vision
Preventative
Other (Describe below)

Please describe other desired coverages (not listed above) here:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements. Your online application in no way constitutes an insurance contract or binder of coverage. Your online application in no way obligates Dewayne White Insurance or any of the companies it represents to bind or contract for insurance coverage for you.