Life
INsurance

We'd love to meet you and find you the perfect solution

Overview

No one really wants to think about life insurance. But if someone depends on you financially, it’s a topic you can’t avoid. In the event of a tragedy, life insurance proceeds can:

-Pay for funeral costs

-Help pay the bills and meet ongoing living expenses

-Pay off outstanding debt, including credit cards and the mortgage

-Continue a family business

-Finance future needs like your children’s education

-Protect a spouse’s retirement plans

Getting life insurance doesn’t have to be hard (or boring). We have some easy steps for you to walk through to see if life insurance is right for you. You’ll also find information and interactive tools to help you get a sense of how much and what kind to buy, plus information about how different life events—such as having children or buying a home—can affect your insurance needs. So why not get started!

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? MaleFemail

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

5) Please provide your height:
ft.
in.

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?
Years
Months

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? YesNo

16) If you have, what do you usually drink? BeerWineLiquor

17) Have you received a DUI Or DWI in the last five years? YesNo

18) Have you been hospitalized in the last five years? YesNo

19) Are you currently taking any prescription medications? YesNo

20) Are you a U.S. citizen? YesNo

21) Have you lived outside the United States anytime during the last three years? YesNo

22) In the future, do you plan to leave the United States for travel or change of residence? YesNo

23) To your knowledge, is there a history in your family (grandparents, parents or siblings) of cardiovascular disease before the age of 60? YesNo

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) YesNo

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? YesNo

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: YesNo

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

Central Nervous System:
EpilepsyMultiple SclerosisAlzheimer's DiseaseCancer

Skin, Bones or Muscles:
Rheumatoid ArthritisMelanomaCancer

Mental Health, Drug Abuse:
AlcoholismDrug AbuseMental IllnessDepression

Digestive System:
Chronic Kidney DiseaseLiver DiseaseKidney StonesGastric/Peptic UlcersUlcerative Colitis or IleitisNeurogenic BladderBowel IncontinenceDiabetes MellitusCancer

Respiratory System:
AsthmaEmphysemaChronic BronchitisCOPDCancer

Circulatory System:
Coronary Artery DiseaseVascular DiseaseHigh Blood PressureStrokeElevated CholesterolCancerHIV

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:

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