Life Insurance Quote

Thank you for your interest in Legere Insurance Agency.
Please enter the following information so we can respond to your request quickly and efficiently. Fields followed by an asterisk(*) are required information.
Note: We are licensed to sell insurance only in Massachusetts.

Contact Information:

Name: *
Street: *
City: *
State: *
Zip Code: *
Email Address *
Phone: *		Home    Business    Cell

Best way to contact you: *

Email:  or Phone:   Time: Choose Time Mornings Afternoons Early Evenings

Coverage Information: 

Amount of * Insurance:		-- Select -- $50,000 $100,000 $150,000 $200,000 $250,000 $300,000
Other:
Term of Coverage: *		-- Select -- 10 years 15 years 20 years 25 years 30 years

General Information:

Date of Birth: *
Sex: *		Male    Female
Height: *
Weight: *
Occupation: *

Which statement best describes your tobacco or nicotine use? *

		Yes, I smoke or use tobacco products
		No, I have never smoked or used tobacco products
		No, I have quit smoking or stopped using tobacco products for over one years
		No, I have quit smoking or stopped using tobacco products for over three years
		No, I have quit smoking or stopped using tobacco products for over five years

Do you have a history of cancer, heart problems, diabetes, alcohol or substance abuse, or treatment for depression or any psychiatric condition? *

Yes    No

If yes, are you taking any prescription medications for any of these conditions?

Yes    No

Has your mother, father or siblings been diagnosed or died from heart disease or cancer prior to age 60? *

Yes    No

Do you have a pilot's license or participate in any hazardous sports or hobbies, such as scuba diving, parachuting, hang gliding, rock climbing, motorized racing? *

Yes    No

Do you have any driving violations in the last five years? *

Yes    No

Do you travel or anticipate travel out of the country? *

Yes    No

If known, please indicate your most recent readings for:

Cholesterol Level:
HDL Ratio:
Blood Pressure  Reading:

How did you hear about Legere Insurance?

		-- Select -- Article in industry publication Advertisement (print) Yellow Pages Banner Ads Direct Mail Internet Search Newspaper Public Relations Web Site Link Word of Mouth
Other:

Would you like to subscribe to our online newsletter?

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