McClure Insurance Company

Insurance Quote Request

Name:
E-mail address:
Address:

City:
State:
Zip:
Day phone:
Evening phone:

Applicant's date of birth:
Applicant's sex:
Is applicant a tobacco user?
Applicant Height/Weight		Feet Inches Weight

Spouse's date of birth:
Spouse's sex:
Is spouse a tobacco user?
Spouse Height/Weight		Feet Inches Weight


Do you need maternity coverage?

Ages of children (If Applicable):

Are you self-employed?		Covered Now?
If covered now, what company?
Type of Plan
Current Premium
When do you need coverage to take effect?

Please list preexisting health conditions that you need to have covered:

High Blood Pressure		Yes No
Cancer		Yes No
Diabetes		Yes No
Anxiety or Depression		Yes No
Asthma		Yes No
Allergies		Yes No
Pregnant		Yes No
Heart Attack		Yes No
Comments

Type of coverage desired:		Major Medical
		PPO
		Short Term Major Medical (30 days-1 yr.)
		Dental
		Medicare Supplement (65 or over)
		Life Insurance
		Disability