Life/Health Insurance Quote Request For an instant quote click here (leave Behnke & Associates website) For your free, personalized, no-obligation insurance quote, please complete the form below. In order to provide you with the most accurate quote as possible, please provide as much information as possible. This information will be kept fully confidential and will be used for quoting purposes only. Please feel confident in providing this information in a private manner, as our connection has been secured with encryption. You may verify this by the existence of a solid key or locked pad-lock on your browser's status bar. Red Identifiers Indicate A Required Field Submission does not bind coverage

Personal Information
Name:
Address:
City:
State:
Zip:
Day Phone:
Night Phone:
Best Time To Call:	AM PM
E-mail Address:

Due to some represented company requirements, we request that you provide your social security number. This is to allow the represented companies to obtain your credit records in order to qualify you for certain discounts. Any such records will be obtained and reviewed by the represented companies only.

By providing this information, you are authorizing these represented companies to obtain and review your records and that these records will be used for quoting purposes only.

Social Security #:

Information About Yourself & Family
Please enter information below for all to be covered.
	Self	Spouse	Child #1
Name:	Self
Date of Birth:
Sex:	M   F	M   F	M   F
Marital Status:	M   S	M   S	M   S
Occupation:
Height:	ft.   in.	ft.   in.	ft.   in.
Weight:	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP
	Child #2	Child #3	Child #4
Name:
Date of Birth:
Sex:	M   F	M   F	M   F
Marital Status:	M   S	M   S	M   S
Occupation:
Height:	ft.   in.	ft.   in.	ft.   in.
Weight:	lbs.	lbs.	lbs.
Have you (they) had any of the following health conditions:	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP	Heart Cancer Diabetes HBP

Individual Histories
Please list any individual histories on each person to be covered.
Self	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #4	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes   No     If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages
	Self	Spouse	Child #1
Amount of Coverage:	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income:	Y   N	Y   N	N/A
Long Term Care:	Y   N	Y   N	N/A
	Child #2	Child #3	Child #4
Amount of Coverage:	$	$	$
Type of Coverage:	Term Whole Universal	Term Whole Universal	Term Whole Universal

Health Coverages
Add Health Coverage?:	Self	Spouse	Child #1
	Y   N	Y   N	Y   N
	Child #2	Child #3	Child #4
	Y   N	Y   N	Y   N
Please check desired coverages for your health plan.
High deductible catastrophic plan No deductible co-pays Maternity Mental Health Chiropractic   Acupuncture Dental Vision Preventative Other (Describe below)
Please describe other desired coverages here:

Additional Comments

Please leave any comments or additional entries here.

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