Rainbow Insurance Agency Ltd - Life Insurance Quick Quote

2425 Burrard Street
Vancouver, B.C., Canada
V6J 3J3

Tel: (604) 736-7668
Fax: (604) 736-4375

Office hours:
Monday - Friday: 9:00 a.m. to 8:00 p.m.
Saturday: 10:00 a.m. to 4:00 p.m.

Life Insurance Quick Quote Form

All estimates confidential, and for ourcompany use only: no access given to outside mailing lists oragencies

Name:
Address:
City:
Province:
Postal Code:
Phone #:
Fax #:
E-mail address:	(required)

General

What is your Birthdate?
What is your height in inches?
What is your weight in pounds?
Are you a smoker or non-smoker?	(A non-smoker has not smoked tobacco or marijauna or used nicotine products for at least one year. A preferred smoker has used tobacco or nicotine products but has not smoked tobacco or used marijauna for at least one year.) Smoker Preferred smoker Non-smoker for one year Non-smoker for two yearsNon-smoker for 15 years or more
How long would you like your life insurance term?	annual 5 years 10 year 20 yearsor to age 100
Would you like permanent life insurance with cash values?	Yes No
Amount of Coverage:	$25,000 $50,000$100,000
	$200,000$300,000$500,000
	$750,000 $1,000,000Other:
Have your parents, your brothers or your sisters had cancer before age 65?	Yes No
Have your parents, your brothers or your sisters had heart disease or stroke before age 65?	Yes No
Do you have any medical problems?	Yes No
If yes, please specify:
Would you like a joint policy with your spouse?:	Yes No
If yes, please fill in the form below:

	Spouse Information
Name:
Birthdate:
Height in inches:
Weight in pounds:
Is your spouse a smoker or nonsmoker?	(A non-smoker has not smoked tobacco or marijauna or used nicotine products for at least one year. A preferred smoker has used tobacco or nicotine products but has not smoked tobacco or used marijauna for at least one year.) Smoker Preferred smoker Non-smoker for one year Non-smoker for two years or moreNon-smoker for 15 years or more
How long a life insurance term would you like?	annual 5 years 10 years20 yearsor to age 100
Amount of Coverage:	$25,000 $50,000$100,000 $200,000$300,000 $500,000$750,000 $1,000,000Other:
Have your parents, your brothers or your sisters had cancer before age 65?	Yes No
Have your spouse's parents, brothers or sisters had heart disease or stroke before age 65?	Yes No
Does your spouse have any medical problems?	Yes No
If yes, please specify:

Do you want coverage on your children?	Yes No
If yes, please specify amount of coverage:	$5,000$10,000$25,000Other:
Name of Child:	Birthdate:
Name of Child:	Birthdate:
Name of Child:	Birthdate:
Name of Child:	Birthdate:

If you have any questions or comments, please enter them here:

Rainbow Insurance Agency Ltd.
2425 Burrard Street
Vancouver, B.C. Canada
V6J 3J3
Tel: (604) 736-7668
Fax: (604) 736-4375

Office hours:
9:00 A.M. to 8:00 P.M. Monday - Friday and 10:00 A.M. to 4:00 P.M. Saturday