Impaired Risk Life Proposal Request

Diversified Insurance Brokers, Inc.

If you are not currently an Agent you will need to complete the Agent Registration form.

Please provide the following contact information:

We request the contact information here to ensure prompt and accurate response to your needs.

Name

Street Address

Address (cont.)

City

State

Zip/Postal Code

Phone (Required)

FAX

E-mail (Required)

Please provide the following information regarding your applicant:

Applicant's Name

Applicant's Street Address

Street Address (Cont)

City

State

Zip/Postal Code

Applicant's Date of Birth

Applicant's Sex Male Female

Applicant's Height

Applicant's Weight

Applicant's Tobacco Use None Cigarettes Cigars Pipe Chew

Applicant's family history:

	Age If Living	State of Health or Cause of Death	Age at Death
Father
Mother
Brothers & Sisters
Brothers & Sisters
Brothers & Sisters

Current health plan:

Plan type
Face amount for current plan
Amount of insurance in force

Medical impairment summary:

Explain current

medical impairments

Actions by other insurance companies:

Insurance company providing quote
Was applicant declined?	Yes No
Rated
Reason for decline
Plan name
Plan amount

Please enter any other comments or questions for the quote.

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Diversified Insurance Brokers Quotation Policy After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual coverage. There is no commitment for filling out the information on this form and receiving a quote. A Diversified representative can complete a personalized quote for you over the phone.

Legal Notice

Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Phone (Required)
FAX
E-mail (Required)

Applicant's Name
Applicant's Street Address
Street Address (Cont)
City
State
Zip/Postal Code
Applicant's Date of Birth
Applicant's Sex	Male Female
Applicant's Height
Applicant's Weight
Applicant's Tobacco Use	None Cigarettes Cigars Pipe Chew

Impaired Risk Life Proposal Request

Copyright ©2001 Diversified Insurance Brokers. All rights reserved. Rev: November 17, 2002