Life Insurance NH, ME - Bernier Insurance, Home - Life - Car

Life Insurance Quote Form

We would like to provide you with a free, no-obligation 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.

Personal Information
Name
Address
City, State, Zip
Home Phone / Cell
Best time to call
Email

	Self	Spouse	Child #1	Child #2
Name:	--
DOB
Sex:	M F	M F	M F	M F
Marital Status:	M S	M S	M S	M S
Occupation:
Height:
Weight	lbs.	lbs.	lbs.	lbs.
Health Conditions	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP

Tobacco use	Never Present Quit**	Never Present Quit**	Never Present Quit**	Never Present Quit**
Tobacco Type	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
Years smoked
**Quit -- Please enter information if any to be insured are FORMER TOBACCO users.
**Quit -- Month/Year:

Is person to be insured currently on any prescription medications for ongoing health conditions? If yes, please list. Also, please DISCLOSE any and all health conditions you have (or had in the past)	Yes No	Yes No	Yes No	Yes No

Life Coverages
	Self	Spouse	Child #1	Child #2
Amount of Coverage:	$	$	$	$
Type	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income:			-	-
Long Term Care:			-	-

Health Coverage	Yes	Yes	Yes	Yes

	Please check desired health plan coverages
	High deductible catastrophic plan No deductible co-pays Maternity Mental Health Chiropractic	Acupuncture Dental Vision Preventative Other (Describe)	Describe other desired coverages



Additional information and comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.