Archer A. Associates, Inc. - Insurance Agents and Brokers
Life Inurance Quote
Life Insurance Information
Type
Amount of Death Benefit
Insured Information
Name *
First Last 
Address *
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Home Phone Number *
### - ### - ####
Email
*
Use Tobacco
Yes
No
Gender
Male
Female
Height
Weight
Insured Medical Information
Describe any pre-existing health conditions.

List below any medication, including dosage and frequency.

Note any other pertinent information or requests for coverage.

Spouse Medical Information
Describe any pre-existing health conditions.

List below any medication, including dosage and frequency.

Note any other pertinent information or requests for coverage.

Children Information
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.

Disability Insurance Information
Occupation
Duties

Earnings

Earnings Frequency
Weekly
Bi-Weekly
Monthly
Yearly
Other Disability Coverage?
Yes
No
Other Disability Coverage Type:
Individual
Group
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD

Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD
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