Georgia Insurance | Brackett Insurance Consultants

Life Insurance Rate Request
Yes! Please take my information and carefully search for the lowest rates with only the A+ rated companies. I understand that this information is held in the strictest of confidence and will only be discussed with the Underwriting Departments for accurate rates.


Name	(first) (last)
City	Zip
Phone	(day) (mobile)
E-mail	(ex: jdoe@isp.com)
How and When do you wish to be contacted?

What death benefit do you need?
How long do you need it to last?
Do you currently have insurance?	Yes No
If Yes, please describe:
Are you thinking of replacing that policy or adding to it?

	Birth Date (ex: 02/15/75)	Sex	Height	Weight	Tobacco Use
Applicant		M F			Yes No
If you answered yes to Tobacco use, please describe the type of tobacco, how long you have used it, and how much you use each day.
Have you filed bankruptcy in the past 10 years? Yes No
Give details of any driving violations in the last 3 years
Give details of any DUIs in the last 5 years
Please list any health issues from the past 2 years including any prescription medications
Have you EVER had cancer, heart disease, or any other major illness? Please provide details

	Age(s) if Living	Age(s) at Death	Reason for Death	History of Cancer?	History of Heart Disease?
Mother				Yes No	Yes No
Father				Yes No	Yes No
Siblings				Yes No	Yes No


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