George Papazoglou
Phone: 734-637-0666
Fax: 866-597-4818
george@miinsurancebrokers.com
www.miinsurancebrokers.com
MI MI Insurance Brokers
BUSINESS   HOME   AUTO   HEALTH   LIFE     CUSTOMER SUPPORT
HOME> QUOTES>
Quotes Forms



Auto Quote Form

Business Quote Form

Home Quote Form

Health & Life Quote Form

 

Health & Life Quote Form

(H)Health - (L)Life Insurance Information
(H): Health (L): Life, If applying for Health Insurance answer only (H) related questions.
If applying for Life Insurance answer only (L) questions.

 
(H)(L): Name of insured, DOB & Gender?
(H)(L): Address?
(H): Any dependents? If yes, Age and Gender?
(H): Dependent #1: Age and Gender if applicable.
(H): Dependent #2: Age and Gender if applicable.
(H): Dependent #3: Age and Gender if applicable.
(H)(L): Name of Insured: Smoker or Nonsmoker?
(H): Dependent #1: Smoker or Nonsmoker?
(H): Dependent #2: Smoker or Nonsmoker?
(H): Dependent #3: Smoker or Nonsmoker?
(H)(L): Named Insured: Pre-Existing Medical Conditions?
(H): Dependent #1: Pre-Existing Medical Conditions?
(H): Dependent #2: Pre-Existing Medical Conditions?
(H): Dependent #3: Pre-Existing Medical Conditions?
(H)(L): Named Insured: Prescription(s)?
If yes, Name of prescription(s),
dosage and frequency of prescription usage?
(H): Dependent #1: Prescription(s)? If yes, Name of prescription(s),
dosage and frequency of prescription usage?
(H): Dependent #2: Prescription(s)? If yes, Name of prescription(s),
dosage and frequency of prescription usage?
(H): Dependent #3: Prescription(s)? If yes, Name of prescription(s),
dosage and frequency of prescription usage?
(L): Type of Life insurance? 10, 15, 20, 25, 30 Yr. Term?
Whole Life? Universal Life?
(L): Amount of Death Benefit?
(L): Any DUIís, DWIís? If yes. How long ago?
Email address?*
Telephone#?*
Additional Information/Comments:*
* For an accurate quote all questions/Fields
must be answered.
 
Michigan Home Insurance © 2010 WWW.MIINSURANCEBROKERS.COM