Life Insurance Quote - Young & Haggis Insurance Services Ltd

Life Insurance Information

Type*

Amount of Death Benefit*

Insured Information

Insured Name*

Date of Birth*

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone*

Email*

Use Tobacco*

Yes
No

Gender*

Male
Female

Height*

Weight*

Insured Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Spouse Insurance Information

Spouse to be Insured?*

Yes
No

Amount of Death Benefit?

Name of Spouse

Spouse Use Tobacco?

Yes
No

Date of Birth

Gender

Male
Female

Height

Weight

Children

Yes
No

Do You Want Insurance For Kids?

Yes
No

Spouse Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Children Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Disability Insurance Information

Do You Want Information for Disability Insurance?

Yes
No

Occupation

Duties

Earnings

Earnings Frequency

Weekly
Monthly
Yearly

Other Disability Coverage?

Yes
No

Other Disability Coverage Type

Individual
Group

Disability Benefits to be Quoted

Elimination Period STD

Percentage Payable STD

Maximum Monthly Benefit STD

Duration of Benefits STD

Elimination Period LTD

Percentage Payable LTD

Maximum Monthly Benefit LTD

Duration of Benefits LTD

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Email

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