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Personal Insurance - Life & Financial Services - Quote

Please complete the following form for a free life insurance quote. The quote is subject to verification of information and inspection. Additional information may be requested.

Please note: These quotes are computed to the best of our ability with the information provided. If the information you provide is incomplete or incorrect, you actual quote may change. Thank you.

Section One - Personal Information
Name:
Address:
City:
State:Massachusetts only, please.
Zip:
County:
Daytime Telephone:
Evening Telephone:
Best time to contact:
Fax:
E-Mail:
Date of Birth
Gender: Male Female
Are you currently a Fitts Insurance customer? Yes No

Section Two - Policy Information
Type of policy:
Term of policy:
Coverage Limit:$

Section Three - Medical History Information
Do you smoke?
If yes, what do you smoke? Cigarettes Cigars
Pipe Chewing Tobacco

If you previously smoked and quit, during what year did you quit?
Height:
Weight:
Do you take any prescription medications? Yes No
If yes, please explain:

Do you have any health problems (Asthma, Cancer, Cholesterol, Diabetes, Heart Disease, Hypertension, or other)? Yes No
If yes, please explain:

Did any of your parents or siblings have heart disease or cancer, prior to age 65? Yes No
If yes, please explain:

Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation? Yes No
If yes, please explain:


Section Four - General Information
Please indicate how you found our web site:
Prior Fitts Insurance Customer
Referral/Word of mouth
Please tell us who referred you:
Newspaper advertisement
Internet banner advertisement
Radio advertisement
Yellow Pages
Internet Search Engine
Google
Yahoo
Altavista
Webcrawler
Lycos
Other :
Other
Any additional comments:




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