Please provide the following information for an accurate quote.
All fields marked with a * are required. 

PRIMARY:   Full Name: *   Gender: M F*

Date of Birth: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 *  Height:ft in  Weight:pounds

SPOUSE:   Full Name:      Gender: M F

Date of Birth: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006     Height:ft in  Weight:pounds

HOW MANY CHILDREN: 0 1 2 3 4 5 6 7 8 9 10   Ages:

Has any person to be insured has been diagnosed with (in the past 10 years):

If any of the above are selected, please indicate who, onset date, diagnosis, and current status:

Is anyone an expectant mother or father? YES NO

Does anyone use tobacco? YES NO If yes, who?

Has everyone to be insured been a US or Canadian resident for the last 12 months?

Does anyone currently take any medications? YES NO 

    If yes, please indicate who, type of medication,, and dosage:

Type of insurance quote requested:

    If requesting a Life Insurance quote, please indicate amount:

Do you currently have:

Zip Code: *  Home #:*  Cell #:   Work #:

Occupation:   Email:*

NOTES

DISCLOSURE:  Where permitted by law, some insurance companies may confirm your information, through the use of consumer reports, which may include credit score and driving record.

By submitting this form I give permission to Medley Insurance to share this information with insurance companies that are contracted with Medley Insurance for the purpose of finding me the best possible price on the insurance services I have chosen.  I also give permission for the individual insurance companies to contact me via email, telephone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to process my reques

Medley Insurance suggests that you keep a completed copy of this form for your records.