LIFE INSURANCE QUOTE		We would like to provide you with a free, no-obligation life insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. This is not an application for insurance, and it does not obligate this agency to issue any policy of insurance. Despite the security measures taken, there are inherent risks of disclosing personal info on the website. If you are concerned, please feel free to call, fax, or mail at your convenience.

General Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Email Address:

Information About Yourself And Family
Please enter information below for all to be covered.
	Self	Spouse	Child #1	Child #2	Child #3
Name:	Self
Date of Birth:
Sex:	M   F	M   F	M   F	M   F	M   F
Marital Status:	M   S	M   S	M   S	M   S	M   S
Occupation:
Height:	ft.   in.	ft.   in.	ft.   in.	ft.   in.	ft.   in.
Weight:	lbs.	lbs.	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP
Please enter information below about TOBACCO usage for all to be covered.
Have you (they) ever used tobacco or nicotine products?:	Never Present Quit**	Never Present Quit**	Never Present Quit**	Never Present Quit**	Never Present Quit**
Type of Tobacco used?:	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum	smokeless cigar cigarette pipe patch/gum
Packs per day:
# of yrs smoked:
**Quit -- Please enter information if any to be insured are FORMER TOBACCO users.
**Quit Month/Year:
Packs per day:
Years smoked?:

Individual Histories
Please list any individual histories on each person to be covered.
Self	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages
	Self	Spouse	Child #1	Child #2	Child #3
Amount of Coverage:	$	$	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income:	Y   N	Y   N	N/A	N/A	N/A
Long Term Care:	Y   N	Y   N	N/A	N/A	N/A

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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HEDLEY BROOK AGENCY, INC.
818 W. State Street, P.O.B. 585, Olean, New York 14760-0585 USA
Tel: 716-372-1122 · Fax: 716-372-1143
TOLL FREE (NY-PA-FL) 1-877-414-1122
info@hedleybrook.com

This is not an offer to sell insurance in any place except the state of NY, USA

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