Life / Health Insurance

Carter & Company, L.L.P.

Life and Health

Life / Health Insurance Quote Form
For the fastest and most accurate life and/or health insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information

Name:
Address:
City:	State: ZIP:
County:	Email:
Phone Day:	Night:
Best time to call:	AM PM

About Yourself:

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have you had any of the following health conditions: Heart Cancer Diabetes HBP

Are you currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions you have (or had in the past):

Do you wish to include your spouse on this coverage quote? Yes No

About Your Spouse (Only if he or she is to be covered):

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have they had any of the following health conditions: Heart Cancer Diabetes HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include your child(ren) on this coverage quote? Yes No

Child # 1 (Only if he or she is to be covered):

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have they had any of the following health conditions: Heart Cancer Diabetes HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote? Yes No

Child # 2 (Only if he or she is to be covered):

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have they had any of the following health conditions: Heart Cancer Diabetes HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote? Yes No

Child # 3 (Only if he or she is to be covered):

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have they had any of the following health conditions: Heart Cancer Diabetes HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Do you wish to include another child on this coverage quote? Yes No

Child # 4 (Only if he or she is to be covered):

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you use any tobacco products?
	Please Indicate With M or F	Please Indicate With M or S		ft in	lbs	Please Indicate With Y or N

Have they had any of the following health conditions: Heart Cancer Diabetes HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Coverages

Please select the following coverages:

LIFE Coverages

Please select if interested in LIFE coverage.

Amount of Coverage (self):	$
Amount of Coverage (spouse):	$
Amount of Coverage (per child):	$
Type of Coverage:	Term Whole Universal
Disability Income Coverage?	Y N
Long term care coverage?	Y N
Coverage for:	Self Spouse Child #1 Child #2 Child #3 Child #4

HEALTH Coverages

Please select if interested in HEALTH coverage.

High deductible catastrophic plan:	Y N
No deductible co-pays:	Y N
Maternity:	Y N
Mental Health:	Y N
Chiropractic:	Y N
Acupuncture:	Y N
Dental:	Y N
Vision:	Y N
Preventative:	Y N
Coverage for:	Self Spouse Child #1 Child #2 Child #3 Child #4

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this Life / Health quote form. One of our representatives will respond to your submission as soon as possible!

Send mail to info@cartercompany.com with questions or comments about this web site.