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Florida Insurance Quote Kenneth Worrow-Broker
Phone: 1 800 330 2233 |
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*Following are Mandatory fields. |
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Personal Information |
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| Date of Birth |
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Month* |
Day* |
Year* |
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| If you currently smoke cigarettes, how many packs daily* |
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| I used to smoke, but quit* |
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| Amount* |
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Type of insurance you're interested in?* |
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| Do you take any
prescription medications* |
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| If yes, state the medication, dosage (if known) and the condition it is treating*
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| Has any of parent sibling had cardiovascular disease or cancer?* |
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| If yes, please explain including age of onset, diagnosis, and death (if applicable)* |
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| Ever been treated for any of the following? (Check all that apply)* |
| If you
checked any of the above, please
explain date of onset or beginning
of treatment, diagnosis, and current
status* |
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| Are you a private pilot or student pilot* |
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| If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.)* |
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| Do you
engage in scuba diving, sky diving,
rock climbing, motorized racing, or
any other hazardous avocation or
occupation?* |
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If yes, please explain* |
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| Have you
been convicted of drunk drining in
the past 7 years?* |
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| Has your drivers
liscense been suspended or revoked in the past 7 years?* |
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| Been convicted of 2
or more moving violations in the
past 3 years?* |
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| Ever been convicted of, or are now awaiting trial for a felony?* |
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| In the past 5 years, have you filed for bankruptcy?* |
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| Are you a United States Citizen?* |
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| If Yellowpages, which one?* |
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