Professionals Choice Insurance Questionnaire

Please send me more information about:

Life Insurance Long-Term Care
Healthcare Service Discounts/Pharmacy Discounts

Information:
Smoker Non-Smoker
Year

Smoker Non-Smoker
Year
Smoker Non-Smoker
Year
Smoker Non-Smoker
Year
Smoker Non-Smoker
Year
Smoker Non-Smoker
Year
Face Amount - Term $ (example: $25,000 for 20 year term)
Have you EVER had or been diagnosed as having any of the following conditions? Check all that apply
Alzheimer's Disease
Amputation due to disease
Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease)
Chronic Hepatitis
Cirrhosis of the liver
Dementia
Hydrocephalus
Multiple Sclerosis
Multiple strokes, CVAs or TIAs
Muscular Dystrophy
Myasthena Gravis
Organic Brain Syndrome
Paraplegia or Quadraplegia
Parkinson's Disease
Polymyositis
Scleroderma
Senility
Other (specify):
Quote provided based on information on the above form. Standard Rates apply -- unless under Preferred Rates.

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Fax: 417-447-1148