Weimer Over Agency Inc.
       10 Franklin Street
       Lancaster, NY  14086      E-Mail: insure@weimerover.com

               Member of Consolidated Insurance Agents, Inc                (716) 683-3323
     



For your insurance needs and a free quote, give us a call. 

©2007, Weimer Over Agency Inc.. All rights reserved.

Address: 10 Franklin Street
Phone: (716) 683-3323
Fax: (716) 683-3358
 

Life and Health
Life Insurance Quote Form
For the fastest and most accurate life 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!

                       Note: Items marked in red are required items and must be
                            answered prior to clicking submit.

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 smoke?
 --  M   F M   S     ft   in  lbs Y   N


 

Have you have 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):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  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):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  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):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  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):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  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):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  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 fill out 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

 

 

Additional Comments:
Please give any additional comments about the coverage you desire:

 

   
 

 
 

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