114 North Main  Street
PO Box 188
Clarion, IA 50525

Phone: 515-532-6653 or
1-800-778-9310
Fax: 515-532-6920

Sumners Life/Health Insurance Quote

Please fill out the information below and click "submit". If you make a mistake click "reset".
Spouse and children are not required for a quote.

General Information
Name:
Address:
City:   State:    ZIP:
County:   Email:
Phone Day: ( ) -            Night: ( ) -
Best time to call:   AM   PM
About Yourself:
Date of Birth Sex  Marital Status  Occupation Height Weight Do you smoke?
 --  M   F M   S     ft   in  lbs Y   N
Have you have had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are you currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions you have (or had in the past):
About Your Spouse (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  N
Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are they currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions they have (or had in the past):
Child # 1 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  N
Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are they currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions they have (or had in the past):
Child # 2 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  N
Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are they currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions they have (or had in the past):
Child # 3 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  N
Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are they currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions they have (or had in the past):
Child # 4 (Only if he or she is to be covered):
Name Date of Birth Sex Occupation Height Weight Smoker?
   --  M  F     ft  in  lbs Y  N
Have they had any of the following health conditions: Heart     Cancer     Diabetes     HBP
Are they currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:
Please DISCLOSE any and all health conditions they have (or had in the past):
Please select the following coverages:
LIFE Coverages
Please select if interested in LIFE coverage.
Amount of Coverage (self): $
Amount of Coverage (spouse): $
Amount of Coverage (per child): $
Type of Coverage: Term
Whole
Universal
Disability Income
Coverage?		 Y   N
Long term care
coverage?
 		 Y   N
Coverage for: Self
Spouse
Child #1
Child #2
Child #3
Child #4
HEALTH Coverages
Please select if interested in HEALTH coverage.
High deductible
catastrophic plan:		 Y   N
No deductible co-pays: Y   N
Maternity: Y   N
Mental Health: Y   N
Chiropractic: Y   N
Acupuncture: Y   N
Dental: Y   N
Vision: Y   N
Preventative: Y   N
Coverage for: Self
Spouse
Child #1
Child #2
Child #3
Child #4

Comments:

PLEASE NOTE: These insurance quote's are estimates and although depict a fairly accurate figure, do not represent the true cost. Because of the many attributes that determine price and coverage an exact figure can only be given after completing a full application.

Copyright © 2000 Sumners Insurance and Real Estate
Designed by Brandon Miller