| What
is Your Name? |
|
| Your
Mailing Address |
|
| City |
|
| State |
|
| Zip
Code |
|
| Your E-mail address
(Be sure to include the @ symbol) |
|
| Gender |
|
| Date
of Birth |
|
| Height |
|
| Weight |
|
| Do you use tobacco products? |
|
| If tobacco user, indicate if you smoke or
chew (dip). |
|
| If former tobacco user, last date used (important!) |
|
| Do you pilot aircraft? |
|
| If so, how
many hours per year? |
|
| Do you participate in hazardous activities
such as hang gliding, mountain climbing, bungee jumping or scuba diving? |
|
|
| List ANY health problems.
IMPORTANT! Be especially sure to note if you have history of diabetes, high blood
pressure, arthritis, cancer or heart disease history. Also, list ALL
Prescription Medication you are now taking. |
|
| This
info is OPTIONAL, but preferred... List any Physician you are seeing or have seen
recently with respect to any health problem listed above. Be sure to
include the physician's address and phone number if possible. We can sometimes speed up your application process with
physician info. |
|
|
 Amount
of Coverage Desired |
$100,000
and up. |
|
Type of Illustration
Requested (check ALL that apply) |
| 5
Year Level Term |
|
| 10
Year Level Term |
|
| 15
Year Level Term |
|
| 20
Year Level Term |
|
| 30
Year Level Term |
|
| Universal
Life Illustration |
Permanent
Type Policy |
| Whole
Life Illustration |
Permanent
Type Policy |
| Do you want
a rider that doubles the benefit if death occurs due to an accident? |
Extra Charge When Available |
|
|
Tell us
How to Get in Touch With You: |
| Telephone
(Serious Inquiries Only Please) |
|
| Fax
(To have your proposal faxed also) |
|
|
|
|
|
|
Turner
& Hamrick, LLC P.O. Box 985 Troy, AL
36081
|
|
440
U.S. Hwy 231 Troy, Alabama 36081
|
|
Phone:
(334) 566-7665 Fax: (334) 566-7215
|
|