Parsons & Associates. Inc. -- Insurance & Risk Management

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


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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. Our goal is to respond to all submissions within two business days.

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We only accept inquiries for insurance written in New York State

General Information
Name:
Address:
City:   State:    ZIP:
County:   Email:
Phone Day: ( ) -            Night: ( ) -
Best time to call:   AM   PM

About Yourself:
Date of
Birth
Soc Sec # 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 proposal?     Yes     No


About Your Spouse (Only if he or she is to be covered):
Name Date of
Birth
Soc Sec # 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 proposal?     Yes     No


Child # 1 (Only if he or she is to be covered):
Name Date of
Birth
Soc Sec # 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 proposal?     Yes     No


Child # 2 (Only if he or she is to be covered):
Name Date of
Birth
Soc Sec # 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 proposal?     Yes     No


Child # 3 (Only if he or she is to be covered):
Name Date of
Birth
Soc Sec # 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 proposal?     Yes     No


Child # 4 (Only if he or she is to be covered):
Name Date of
Birth
Soc Sec # 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 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 Proposal form. One of our representatives will respond to your submission as soon as possible!

Copyright 2000 - Parsons & Associates, Inc. -- All Rights Reserved