Butler & Associates - Individual Life Insurance

Group and Individual Insurance and Finance in Massachusetts

In order to obtain a Life Insurance quote that best reflects the rates you may be able to obtain, please answer the questions below. Quotes available to individuals located in the state of Massachusetts only.

Quotes provided are based on information provided. Final rates are determined by the Insurance Carrier once the application has been submitted with any other requirements and been reviewed by an Underwriting Department.

To receive a quote for life insurance, please fill out completely and submit the form below. *denotes required information.

Name*:

Address*:

City*:

State*:

Zip*:

Contact E-Mail*:

Phone Number*:

ext:

Fax Number :

Date of Birth*:

/ / (format: MM/DD/YYYY)

Gender*:

Height*:

Weight*:

Are you a citizen of the United States? *: Yes No

If you are on medication, please identify by name, how much you take, how often you take it, and the reason you take it. Also list any medical conditions you may have.

Have you used tobacco in the last five years?* Yes No

Have you lived outside the United States during the last 3 years?		Yes No

Do you plan to leave the United States or Canada for travel or residence within the next 12 months?		Yes No

During the last 2 years, have you worked in any type of hazardous occupation?		Yes No

Do you participate in any risky activities such as racing, scuba diving, sky diving, mountain climbing, para-sailing or ultra light flying?		Yes No

Are you an active member of the military or military reserve?

Have you flown on an aircraft as a pilot, co-pilot or crew-member within the last 3 years?


Have you received 3 or more moving violations, or had your license suspended/revoked within the last 5 years? If yes, when was the most recent occurrence?

Have you been convicted of reckless driving or driving under the influence within the last 5 years? If yes, when was the most recent conviction?

Coverage amount

Reason for coverage

Desired term length

5 years
10 years
15 years
20 years
30 years

Permanent :

Payment terms desired :

When would you like to apply :

Additional comments and/or health issues:

Past performance of an investment is not a guarantee of future results. Securities sold through Clary Investment and Insurance Planning Corporation, P. O. Box 275, North Easton, MA 02356

195 Washington Street, North Easton MA 02356
Tel: 508-230-SAVE/7283

All material copyright � 2008 Butler & Associates.

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