Form

Have any of your family members been treated for cancer, heart disease, stroke or an aneurysm prior to the age of 60?:

Select:

Yes

No

HAVE YOU BEEN TREATED BY ANY OF THE FOLLOWING

Cancer

Heart Disease

Stroke

Corona Virus

None

What type of insurance will you apply for?

Travelling Life Insurance

Business Insurance

Farm Insurance

Residential Insurance

Choose how many years insurance you want to purchase

1 YEAR BASIC PLAN ____________ $200 USD

1 YEARS GOLD PLAN____________ $350 USD

2 YEARS PLAN____________ ______ $900 USD

1 YEAR FAMILY PLAN____________ $1100 USD

2 YEARS FAMILY PLAN____________ $2000 USD

5 YEARS FAMILY PLAN____________ $3500 USD

In the past three years have you been convicted of DUI or had a drivers license suspended/ revoked?

Yes

No