At NEC Insurance Agency, Inc. We put the power of the internet to work for you! Please take a moment to answer the following questions. Remember, this information is needed to find the best the best rate for you, so please answer it as accurately and completely as possible.

1) What type of Other life insurance are you seeking:

2) Please indicate the coverage amount:

3) What is your gender?  Male Femail

4) What is your date of birth: [DD/MM/YYYY]

5) Please provide your height:

6) What is your weight? lbs.

7) Please indicate your marital status:

8) What is the highest Level of education you completed:

9) What is your current employment status:

10) Please select the industry which best describes your occupation:

11) How long have you been at your present job?

To help us ensure that our search delivers the most competitive quote for your Term insurance, we’ll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge

12) In the past five years, have you used any form of tobacco or a nicotine substitute?

13) If you have, what forms of tobacco did or do you use?

14) If you currently smoke cigarettes, how many packs do you smoke per day?

15) Have you used any form of alcohol in the past five years?  Yes No

16) If you have, what do you usually drink?  Beer Wine Liquor

17) Have you received a DUI Or DWI in the last five years?  Yes No

18) Have you been hospitalized in the last five years?  Yes No

19) Are you currently taking any prescription medications?  Yes No

20) Are you a U.S. citizen?  Yes No

21) Have you lived outside the United States anytime during the last three years?  Yes No

22) In the future, do you plan to leave the United States for travel or change of residence?  Yes No

23) To your knowledge, is there a history in your family (grandparents, parents or siblings) of cardiovascular disease before the age of 60?  Yes No

24) During the last 2 years, have you worked in any type of hazardous, occupation? (for example underground mining, high-rise construction, work or explosives handling)  Yes No

25) Are you an active member of the military or military reserve?

26) Have you flown on an aircraft as a pilot, co-pilot or crew-member, within the last 3 years?

27) Do you participate in any risky activities such as racing, scuba, diving, sky diving, mountain climbing, para-sailing or ultra light, flying?  Yes No

28) Have you suffered any health symptoms related to the conditions listed below? If so, please check the box next to the specific condition (s) that you have been advised you had or have been treated for:  Yes No

IF yes please Select all that Apply.. Thank You.

Central Nervous System:
 Epilepsy Multiple Sclerosis Alzheimer's Disease Cancer

Skin, Bones or Muscles:
 Rheumatoid Arthritis Melanoma Cancer

Mental Health, Drug Abuse:
 Alcoholism Drug Abuse Mental Illness Depression

Digestive System:
 Chronic Kidney Disease Liver Disease Kidney Stones Gastric/Peptic Ulcers Ulcerative Colitis or Ileitis Neurogenic Bladder Bowel Incontinence Diabetes Mellitus Cancer

Respiratory System:
 Asthma Emphysema Chronic Bronchitis COPD Cancer

Circulatory System:
 Coronary Artery Disease Vascular Disease High Blood Pressure Stroke Elevated Cholesterol Cancer HIV

29) What range best describes your approximate household income:

30) Do you own or rent your residence:

31) Time at current residence:

32) Please describe your credit history:

33) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

The answer to these basic questions will help us process your information.

Do you own or rent your residence:

Best Time To Contact:    

1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                

9. Zip Code: