Sottile Insurance Information Request
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First Insured: Gender- Male Female
City / Zip Code: Telephone:
Email Address:
Date of Birth: Height-feet/inches Weight-pounds
Check all those conditions for which you have been treated or sought treatment.
Chronic Kidney or Liver Disease
Emphysema(Chronic Bronchitis)
Ulcerative Colitis or Ileitis
Epilepsy(Seizure disorder)
Kidney Stones(last 2 years)
Coronary Artery Disease
Gastric/Peptic Ulcers
Vascular Disease
Mental Illness
Depression
Stroke












Cancer
Neurogenic Bladder
Multiple Sclerosis
Bowel Incontinence
Alzheimer's Disease
Rheumatoid Arthritis
Alcoholism/Drug use
Diabetes Mellitus
Melanoma
Asthma
Hypertension









Have you ever taken blood pressure medication? Yes No
Have you ever taken cholesterol medication? Yes No
Have you used any tobacco products (cigarettes, cigars, dip, snuff, chewing tobacco, pipe tobacco) or any nicotine substitutes in the last 5 years? Yes No
To your knowledge, has anyone in your family (parents or siblings) had cardiovascular disease before age 60? Yes No
Has cancer resulted in the death of an immediate family member (parents or siblings) before the age of 60? Yes No
Please list any medications you are currently taking-
Coverage Options and Term Limit
Option One-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
Option Two-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
Option Three-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
2nd Insured-Optional
2nd Insured: Gender- Male Female
City / Zip Code: Telephone:
Email Address:
Date of Birth: Height-feet/inches Weight-pounds
Check all those conditions for which you have been treated or sought treatment.
Chronic Kidney or Liver Disease
Emphysema(Chronic Bronchitis)
Ulcerative Colitis or Ileitis
Epilepsy(Seizure disorder)
Kidney Stones(last 2 years)
Coronary Artery Disease
Gastric/Peptic Ulcers
Vascular Disease
Mental Illness
Depression
Stroke












Cancer
Neurogenic Bladder
Multiple Sclerosis
Bowel Incontinence
Alzheimer's Disease
Rheumatoid Arthritis
Alcoholism/Drug use
Diabetes Mellitus
Melanoma
Asthma
Hypertension









Have you ever taken blood pressure medication? Yes No
Have you ever taken cholesterol medication? Yes No
Have you used any tobacco products (cigarettes, cigars, dip, snuff, chewing tobacco, pipe tobacco) or any nicotine substitutes in the last 5 years? Yes No
To your knowledge, has anyone in your family (parents or siblings) had cardiovascular disease before age 60? Yes No
Has cancer resulted in the death of an immediate family member (parents or siblings) before the age of 60? Yes No
Please list any medications you are currently taking-
Coverage Options and Term Limit
Option One-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
Option Two-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
Option Three-Select the coverage amount for your term life policy $ Term of 5yr 10yr 20yr 30yr
Additional Comments:
Referred by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.