42 Pine Street   ·   Lockport, NY  14094   ·   PHONE 716-433-9199   ·   FAX 716-433-9297  ·  1-800-557-2947 Search our site:   Term Life Insurance Quote First & Last Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   Self Name: Date of Birth Sex: Martial Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Spouse Name: Date of Birth Sex: Martial Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Children Name: Date of Birth Amt. of Coverage $ Type of Coverage Term Whole Universal Term Whole Universal Term Whole Universal Additional Comments: