ALLiS Login | phone icon (877) 254-4429

Quote Request: Preliminary Health & Family History Information

Advisor Information

Proposed Insured

Contact Information

Current Address

Occupation

Lifestyle Details

Tobacco/Nicotine Type 1

Example: 1 pack daily

Please specify the number of dives and average time underwater per dive for the depth ranges below:

Please specify the number of dives and average time underwater per dive for the depth ranges below:

Please include date and location

Health Details

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Cancer Type 1

Example: Nightly use of CPAP

Family History

Mother

Father

Siblings

Example: Brother, living, age 54, dx with heart disease at age 50

Delivery Options

Additional details you'd like to include to help us with the quote.