All Lines Insurance - Auto, Health, Life, Home, Business, Progressive, Mercury, MetLife, Prudential, Free Quotes, Weston, Florida, Miami, Ft. Lauderdale.

5
MEMBER

Serving
South Florida
Since 1970

Independent Insurance Agent

Life Insurance Quote Form

Please fill out the information requested below. All information is confidential.

Personal Information

Name:

Address:

City:

State

Zip Code:

Phone:

Fax:

E-mail:

Gender:

Date of Birth:

Height:

Your Weight:

pounds

Amount of Life Insurance to quote:
Hold down Ctrl key and click to select multiples.

Type of Insurance:

Type of Coverage:

	New
	Additional
	Replacement

Tobacco/Nicotine Use:

	I have never smoked.
	Haven't smoked in Months, Years
	I smoke packs a day
	I smoke pipe
	I chew tobacco

Do you take any medication ?

If yes, what kind:

Do you have any health condition ?

Yes No

Have you ever been advised or treated for any of the following? (Check all that apply)

AIDS
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Cholesterol
Pulmonary Disease
Depression
Diabetes
Heart Disease

Hypertension
Kidney or Liver Disease
Mental Illness
Stroke
Colitis or Ileitis
Vascular Disease
Other

Are you a pilot or a student pilot ?
Yes No, If yes, explain below the type.

Hazardous activities:
Scuba diving
Sky diving
Rock climbing
Motorized racing
Other:

Drunk Driving conviction ?

2 or more moving violations ?

Any Felony ? Yes No, if yes, explain

Did any of your parents ever had a cardiovascular disease or cancer, prior to age 60? Yes No

If yes, please explain.

Comments

All Lines Insurance

Donna Adelkopf CIC, CPIA

1290 Weston Road, Suite 200

Fort Lauderdale, FL 33326

Phone: (954) 384-6100, Fax: (954) 384-6133

Info@all-lines-ins.com

Home of the Eagle

AUTO

BUSINESS

HEALTH

HOME

LIFE

MECHANICAL
BREAK DOWN PROTECTION

Representing

Mercury Insurance Group

MetLife Auto

Prudential

Progressive

$100,000
$200,000
$300,000
$400,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
$2,750,000
$3,000,000
$3,250,000
$3,500,000
$3,750,000
$4,000,000
$4,250,000
$4,500,000
$4,750,000
$5,000,000
$5,500,000
$6,000,000
$6,500,000
$7,000,000
$7,500,000
$8,000,000
$8,500,000
$9,000,000
$9,500,000
$10,000,000
OVER $10,000,000