Life Insurance Quote


Please include as much information as possible,
or you can call for a quote at (317) 776-6781

Insured(s) Information

Last Name:     First Name:  Phone:  

Address:      City:  State:  Zip:  

Family Information 

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Name:     DOB:  Sex:   Ht:  Wt:  Tobacco (Y/N):

Health Status Questions

1. Is anyone pregnant in the family, or any woman pregnant by a family member? Yes: No:
2. Does anyone in the family have an existing health condition or disorder? Yes: No:
3. Is anyone in the family taking medications and/or Rxs for any reason? Yes: No:
4. In last 10 yrs has anyone been an in-patient in a hospital? Yes: No:
5. In last 10 yrs has anyone seen a doctor for anything other than a checkup or seasonal illness? Yes: No:
6. Anyone with 2 or more traffic violations in the last 3 yrs? Yes: No:

Give complete details of any "Yes" answers to Questions 1-6 in box below
 

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    Please note: Accurate information speeds up the quotation process. Also, all information collected from the forms on this site is considered confidential to Harbour House Insurance and will not be sold or given to any third party under any circumstance. Once your information has been received you will be contacted as soon as possible by one of our personal insurance specialists to discuss your personalized insurance quote.

    Information provided to Harbour House Insurance is secure to protect your information. Harbour House Insurance does not sell information, and the information received will not be used for any other purpose than to provide an insurance quote.