If you have any questions, please call (818) 987-5000
*State of Residence:
*Date of Birth: / /
*Gender: Male   Female
*Height:     Weight: 
*Any tobacco Use:
*Coverage Amount:
*What type of life insurance are you looking for?:
If other, please describe the type of coverage you are looking for:
*First Name:
*Last Name:
City Zip
*Daytime Phone: Ext.:
The coverage to be quoted will likely be:
*Are you a citizen of the United States?
*Have you lived outside the United States during the last 3 years? Yes No
*Did any of your parents or siblings have cardiovascular disease, prior to age 60? Yes No
*Are you a private pilot or student pilot? Yes No
If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.):
*Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation? Yes No
If yes, please explain in detail:
*In the past , have you been found guilty of reckless driving or driving under the influence (DUI/DWI) or had your driver's license suspended/revoked?
*In the past, have you received 3 or more moving violations?
*Have you ever been convicted of, or are you awaiting trial for a felony? Yes No
*Do you take any prescription medications? Yes No
If yes, please state name of medication, dosage (if known), and the condition it is treating:
*Do you have any health conditions? Yes No
If yes, please explain:
Have you ever been advised or treated for any of the following? (Check all that apply)
Alcohol or Drugs
Alzheimer's Disease
Chronic Obstructive Pulmonary Disease
Heart Disease
Kidney or Liver Disease
Mental Illness
Ulcerative Colitis or Ileitis
Vascular Disease
If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status:
Any other Questions or Comments?

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*Competition between life insurance companies and the increasing life span of the average American has caused term life insurance prices to decrease dramatically over the last 10 years. Prices can vary by hundreds of dollars a year between one company and the next.I as and agent can shop and find the most competitive rate with most major insurance companies. on average people save up to 65% . of cause its depend on your health and age, hobbies .

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Oleg Skurskiy

Authorized Independent Agent
Fax: 1-818-776-9865

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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389