Life Insurance

Corbett Insurance
121 South Memorial Highway
Shavertown, PA 18708

Name of person being insured:

Address:

Male


	Female


	Date Of Birth


	Phone


	Have you used products containing nicotine in the past 3 years? If so, which type:

Cigarettes

Pipe Tobacco

Cigars

Others Products Containing nicotine

Chew Or Snuff


	Have you or any of your siblings or parents been diagnosed with cancer, heart disease, diabetes, or any other congenital disorder? If so, whom and at what age were they?


	If any, when is the last time used?


	12 months

	13-24 months

	25-36 months


	Do you currently take any medications (besides vitamins or contraceptives?) If so, what are they?

Do you have any high blood pressure or cholesterol?

Amount Of Insurance Desired

Plan Desired

If Term, years premium level period?


	Yes


	No


	Height


	Weight