Parsons & Associates, Inc. -- Life / Health Proposal Form

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

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!

This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. 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!