Health & Life Insurance

Please complete the form below or call Smith Insurance
today to talk to a representative. (860) 739-3322

 
  Type
  Amount of Death Benefit
 
  Insured Name *
  Address
  City
  State
  Zip
  Home Phone
  Email
  Use Tobacco Yes  No
  Gender Male  Female
  Height
  Weight
 
  Describe any pre-existing Health conditions
  List below any medication, including dosage and frequency
  Note any other pertinent information or requests for coverage
 
  Spouse to be Insured? Yes  No
  Spouse Use Tobacco? Yes  No
  Gender Male  Female
  Height
  Weight
  Children Yes  No
 
  Describe any pre-existing Health conditions
  List below any medication, including dosage and frequency
  Note any other pertinent information or requests for coverage
 
  Gender
Child 1 Male  Female
Child 2 Male  Female
Child 3 Male  Female
 
  Describe any pre-existing Health conditions
  List below any medication, including dosage and frequency
  Note any other pertinent information or requests for coverage
 
  Occupation
  Duties
  Earnings
  Earnings Frequency Weekly  Monthly  Yearly
  Other Disability Coverage? Yes  No
  Other Disability Coverage Type Individual  Group
 
  Elimination Period STD
  Percentage Payable STD
  Maximum Monthly Benefit STD
  Duration of Benefits STD
  Elimination Period LTD
  Percentage Payable LTD
  Maximum Monthly Benefit LTD
  Duration of Benefits LTD
  Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.