Debbie Cheselske
Tel: 559-824-2300
Email: cheselske@sbcglobal.net 		Term & Annuity Store
Toll free: 877-437-9333
“Protecting Your Most Valuable Assets, Guaranteed!”

Welcome to the Term & Annuity store, the fastest and easiest way to shop for your life insurance.
Simply fill out the questions below, and we will then shop the market and email you the
Rates for the top 5 companies.

 

 
1. Correct spelling of your name?
(Proposed insured #1)
 		2. Additional Name .. See Page 2
(Proposed insured #2)
3. DOB: 4. Height & weight
H   W
5. Which type of quote?
Term LifeWhole LifeBoth
 10 year15 year20 year
 30 yearTo age 120
Death Benefit Amount $ 		6. Medical Conditions?
 High Blood Pressure
 High Cholestrol
Diabetes -
Diet Control
 Oral Control
 Insulin Control
Heart Disease
 Cancer
7. Smoker? Yes No
If yes: 		 
8. List all Medication(s):
9. Hazardous activities?
Example:
Skydiving, scuba diving, rock climbing
 Yes No		 10. Email address:
11. Family History (fill the form below..)
  Age (if living) Condition of Health Age (at death) Cause of Death
 Father
 Mother
 Siblings
12. Any foreign travel within the past or
Next 2 years? Yes No		 13. Contact phone numbers?
Home:
Work:
Cell:
14. Do you have existing coverage?
 Yes No
If marked yes:
Company:
Death Benefit:
U.L. Life    Term Life
Whole Life  Group
  15. Best time to call?
 AM PM
Hours:
16. Referred By:
 
    

 
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