# New Underground Railroad - Life Insurance

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Life Insurance Quote

Name:
Address:
City:
State:	Zip:
# of Years:
Phone:
Email:
Sex:
Date of Birth
Birth State

Insurance Plan

Amount of Coverage:
If Universal Life:
If term Indicate Years:

Non Medical History

Has Proposed Insured:

1. Used tobacco or nicotine of any kind over the last 5 years?
2. Consulted a physician or had treatment for the use or possession of:
A. Alcohol?
B. Narcotics, stimulants, sedatives, hallucinogenic drugs?
3. In the past 5 years, been convicted of:
(A) two or more moving violations,
(B) driving under the influence of alcohol or other drugs,
(C) had their driver's license suspended or revoked?
4. Have any proposed insureds ever been convicted of, or pled guilty or no contest to a felony, or do they have any such charge pending against them?
5. Flown as a pilot, or crew member, or intend to fly as such during the next 2 years?
6. Been a member of, or applied to be a member of, or received a notice of required service in, the armed forces, reserves or National Guard? If 'Yes', please list: branch of service, rank, duties, mobilization category and current duty station.
7. Engaged in auto, motorcycle or boat racing, parachuting, skin or scuba diving, skydiving, or hang gliding or other hazardous vocation or hobby?
8. Had a request for life or health insurance declined, postponed, rated, canceled, or restricted in any way?
9. Any application for any other life or health insurance on your life now pending or contemplated in this or any other company?
10. During the next 2 years, is there an intention that any party, other than the owner, will obtain any right, title, or interest in any policy issued on the life of the proposed insured as a result of this application?
11. Is Proposed Insured: A citizen of any other country besides U.S.? If so, what country?

Medical History

12. Have you ever been treated for or told by a physician you had:

A. Cancer, diabetes, epilepsy, heart disorder, high blood pressure, stroke, mental or nervous disorders, tumors, ulcers, or any disorder of bladder, kidney, liver or lungs?
B. Arthritis, gout, or other disorders of muscles, joints, spine, stomach, intestines, or chest pain or asthma?
13. Been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
14. Within the last 12 months, had any kind of medication prescribed?
15. Been advised to have, or contemplated having a surgical operation?
16. Within the last 5 years, suffered from any disease, or received medical or surgical treatment for any condition not listed in question 12?
17. List current height and weight for all persons proposed for coverage. Height - Weight -

Contact Us

The Henderson Financial Group
5783A N.W. 151 Street
Miami Lakes, Fl 33014
Ph : 305-825-1444
Fax: 786-230-8392
info @ newundegroundrailroad.com

Charlotte Office

6135 Park South Drive
Suite 510
Charlotte, North Carolina, 28210
PH: 704-749-3830
Fax: 704-919-5208
charlotte @ newundegroundrailroad.com

Schedule a FREE Financial Consultation:
704-749-3830