Samel/Paramount Insurance Agency | Request for a Life Insurance Quote (NH)

Personal service from a professional agency
serving New England for over 65 years!

Request a Life Insurance Quote

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By completing and submitting this form, you agree that no coverage is bound and no policy is in effect until you are contacted by one of our agency representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible, please complete all areas that apply.

General Information

Full Name

Address

City

State

ZIP Code

Email Address

required

Telephone

Date of Birth

(mm/dd/yyyy)

Use Tobacco

Gender

Height

feet inches

Weight

Life Insurance Information

Type

Amount of Death Benefit

Medical Information for Life Insurance

Describe any pre-existing health conditions

List any medications, including dosage and frequency

Note any other pertinent information or requests for coverage

Health Insurance Information

Spouse to be insured?

Spouse Date of Birth

(mm/dd/yyyy)

Spouse Use Tobacco?

Spouse Gender

Spouse Height

feet inches

Spouse Weight

pounds

Children?

If yes, please complete:

	Date of Birth	Gender
Child #1
Child #2
Child #3

Medical Information for Health Insurance

Describe any pre-existing health conditions

List any medications, including dosage and frequency

Note any other pertinent information or requests for coverage

Disability Information

Occupation

Duties

Earnings

$ Weekly Monthly Annually

Other Disability Coverage?

If yes, what type? Individual Group

Benefits to be Quoted

STD

LTD

Elimination Period

Percentage Payable

Maximum Monthly Benefit

Duration of Benefits

Medical Information for Disability Insurance

Describe any pre-existing health conditions

List any medications, including dosage and frequency

Note any other pertinent information or requests for coverage

Additional Comments