TermHouse.com - Life Insurance, Auto, Health & Mortgage

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	Preliminary Application
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Preliminary Term Insurance Application

CONTACT INFORMATION
First Name
Last Name
How do you prefer to be contacted	Phone Fax Email
Street Address
City
State
Zip
Home Phone
Work Phone
E-Mail
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PERSONAL INFORMATION
Gender
Date of Birth	19
Height
Weight
Amount of Coverage
Length of Coverage
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LIFESTYLE INFORMATION
Have you ever used Use Any Form of Tobacco?
If yes, what type?
If yes, has use been discontinued?	Yes No
When Did You Quit?
In the past five years have you engaged in flying as a pilot, ballooning, parachuting, skydiving, hangliding, vehicle racing, scuba diving, mountain climbing or any similar avocation? Yes No
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INSURANCE INFORMATION
Do you have any current life insurance in force?	Yes No
If yes, with which company?
Do you intend to use this new policy, if issued, to replace an existing policy?	Yes No
Have you applied with any other life insurance company in the last 120 days?	Yes No
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MEDICAL HISTORY
Have you ever received medical advice or treatment for high blood pressure, cholesterol, diabetes, cancer, heart disease, heart murmur, chest pain, asthma, alcoholism, drug abuse, Chrohn's disease, depression or anxiety, emphysema, epilepsy, kidney or liver disease or dysfunction, melanoma, stroke, colitis, arthritis, or any other significant medical condition or do you take any medication? Yes No
Has anyone in your immediate family (parents, siblings) been diagnosed with cancer or cardiovascular disease or suffered a heart attack or stroke prior to age 60? Yes No
In the past 5 years have you had 2 or more moving violations and/or accidents, DWI's, DUI's, or reckless driving or had your driver's license suspended or revoked? Yes No
Have you ever been convicted of or are awaiting trial for a felony? Yes No
In the past 5 years have you traveled outside the US or do you intend to in the next 2 years? Yes No
If you answered "yes" to any question 10 through 19, please provide details below:

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