Insurance 101 (iii Insurance Information Institute)

5907 Business Highway 51, Schofield, WI 54476
Phone: 715-359-8119   |   Fax: 715-359-9294

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Call Us At: 715-359-8119

Klasinski Insurance Agency - Home | Auto | Life | Health
5907 Business Highway 51, Schofield, WI 54476    |    Phone: 715-359-8119   |   Fax: 715-359-9294

Life Insurance Quote

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Bold = Required field
Person To Be Insured
Date of birth
Gender
Marital Status
Height
Weight
Has this person used any tobacco products in the past 12 months?
Is this person an expectant mother or father?
Select any of the following that the person to be quoted has been diagnosed with (in the past 10 years):
If you've selected any of the above, please provide date of onset, diagnosis, and current status:
Does this person take any medications?
If Yes, please list medication name and dosage:
Any immediate relatives who have ever had heart disease?
Any immediate relatives who have had any form of cancer?
Has this person been a U.S. or Canadian resident for at least 12 months?
What is this person's highest education level?
Past or Present Military experience
What is this person's occupation?
Is this individual a private pilot or student pilot?
Does this person engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation?
Has this person been convicted of drunk driving in the past 7 years?
Driver's license been suspended or revoked in the past 7 years?
Been convicted of 2 or moving violations in the past 3 years?
Ever been convicted of, or are now awaiting trial for a felony?
In the past 5 years, have you filed for bankruptcy?
If you answered Yes to any of the above 7 questions, please provide any further information you feel would help explain your answer:
Contact Information
First Name
Last Name
Address
City
State
Zip Code
Phone Number
E-mail Address
Life Insurance Coverage For All Family MembersComplete The Form For A Life Insurance Quote
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