Hansen & Associates Offers You:

First Name:	*
Last Name:	*
Middle Initial:
Address:	*
Apartment:
City:	*
State:	*	AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WY Don't see your state listed?
Zip:	*
County:	*
Phone:	*	Home Office Cell
Email:	*
Periodically, we send out email communications to inform our customers of new products, special offers, and discount opportunities. May we include you on our list of recipients? * Yes No
Gender:	*	Male Female
Date of Birth:		In mm/dd/yyyy format. Ex.: 04/27/1965

Which type of plan interests you?
Term Life Universal Life Whole Life

When will you be purchasing insurance coverage?
1-15 days 15+ days

Do you currently have life insurance? *
Yes No

These next four medical questions are important to know in order to provide you with an accurate quote:

Are you a smoker? *
Yes No

Do you have a heart condition or have you had a heart attack or stroke? *
Yes No

Do you have a tumor or any malignant cancer? *
Yes No

Do you have AIDS or HIV? *
Yes No

If you answered "yes" to any of the above questions, please explain:


Additional health concerns or comments: