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Life Insurance Quote Form
Bank Name
Referred By
Date		5/15/2008 8:16:59 PM
Client Information
Name
Best Time to Call			AM			PM
Phone	Home				Work				Cell
Address
City					State				Zip
Date of Birth					Age
Height					Weight
Smoker							Yes		No
If client has quit, how long has it been?
Has your client been diagnosed with Diabetes?							Yes		No
Medical Conditions Treated in the Past 10 Years										Add One
1	Condition							Date of Onset
2	Condition							Date of Onset
3	Condition							Date of Onset
Medications Currently Taking										Add One
1	Medication							Dosage
Taken For								Times/Day
2	Medication							Dosage
Taken For								Times/Day
3	Medication							Dosage
Taken For								Times/Day
Hospitalizations in the Past 10 Years										Add One
1	From					To
Reason
Result
2	From					To
Reason
Result
3	From					To
Reason
Result
Type of Coverage Requested
Amount Required
Term				5 yr		20 yr		30 yr		Universal Life
				10 yr		25 yr				Whole Life
Existing Coverage Now						Yes		No
Will This Replace Existing Coverage?						Yes		No
If Yes, please provide most current copy of policy statement(s). Please fax completed form to the SCBA at (803) 799-8090. Questions? Contact the SCBA at (803) 799-0850 or IQ@scbankers.org. You may also access this form at www.scbankers.org. Thank you for your business!