Walock-Johnson Insurance, Inc. | Life Insurance Quote Request

Life Insurance Quote Request

It will be our privilege to provide you with a free, no-obligation 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.

General Information

Full Name

Email Address

REQUIRED

Telephone

Address

City

State

ZIP Code

Date of Birth

(mm/dd/yyyy)

Use Tobacco

Gender

Height

feet inches

Weight

Life Insurance Information

Type

Amount of Death Benefit

Medical Information for Life Insurance

Describe any pre-existing health conditions

List any medications, including dosage
and frequency

Note any other pertinent information or requests for coverage

Health Insurance Information

Spouse to be insured?

Spouse Date of Birth

(mm/dd/yyyy)

Spouse Use Tobacco

Spouse Gender

Spouse Height

feet inches

Spouse Weight

Children?

Child(ren) Information

Child #	1	2	3
Date of Birth:
Gender:

Medical Information for Health Insurance

Describe any pre-existing health conditions

List any medications, including dosage and frequency

Note any other pertinent information or requests for coverage

Disability Information

Occupation

Duties

Earnings

$
Per Week Per Month Annual

Other Disability Coverage?

If yes, what type? Individual Group

Benefits to be Quoted

Short-Term Disability (STD)

Elimination Period

Percentage Payable

Maximum Monthly Benefit

Duration of Benefits

Long-Term Disability (LTD)

Elimination Period

Percentage Payable

Maximum Monthly Benefit

Duration of Benefits

Medical Information for Disability Insurance

Describe any pre-existing health conditions

List any medications,
including dosage and frequency

Note any other pertinent information or requests for coverage

Additional Comments

Rutland 701-724-6484		Lisbon 701-683-5253		Milnor 701-427-5215		Gwinner 701-678-2771