Request Life Insurance Quote

Name

First Name

Last Name

Phone Number

(###)

###

####

Email Address

Date of Birth

YYYY

Gender

Male

Female

Have You Used ANY Tobacco Products in the Last 12 Months?

Yes

Coverage Amount

General Rule is approximately 10 to 20 times your Annual Gross Income.

Specify Other Coverage Amount

Term Length

State

Have You Ever had HIGH BLOOD PRESSURE, HEART DISEASE, or HEART ATTACK?

If YES, Provide Details, Dates, and Treatment/Medications

What is Your CHOLESTEROL Level?

What is Your CHOLESTEROL/HDL RATIO?

Do You Take CHOLESTEROL Medication?

If YES, List CHOLESTEROL Medications

Do You Personally Have a History of Cancer?

If YES, 1) What Type? 2) When Were You Diagnosed? 3) Are You Cancer Free and for How Long?

Are You Diabetic or Pre-Diabetic?

If YES, 1) Age When Diagnosed? 2) List Any Medication & Dosage Taken Per Day

Height

Weight

Have Either of Your Parents or Siblings been Diagnosed or Died from Cancer, Stroke, Diabetes, or Cardiovascular Disease Prior to Age 60?

If YES, List Your Relationship, Diagnosis, and Result: (ie Mother, breast cancer age 55, 20 year survivor OR brother, heart attack age 46, deceased)

Do You Have Any Other Major Health Issues or Take Any Prescription Drugs Not Mentioned Above?

4112 W. St. Joe Hwy, Ste C, Lansing, MI 48917 | Phone: (517) 886-0040 | Fax: (517) 886-0804

Advisory services offered through HBW Advisory Services LLC and Blue Diamond Enterprises, LLC dba Blue Diamond Financial Solutions. Blue Diamond Enterprises, LLC dba Blue Diamond Financial Solutions and Blue Diamond Financial Coaching LLC are under separate ownership from any other named entity. Named entities do not offer legal or tax advice.

This site is published for residents of the United States only. Not all of the products and services referenced on this site may be available in every state and through every advisor listed.

We take protecting your data and privacy very seriously. As of January 1, 2020 the California Consumer Privacy Act (CCPA) suggests the following link as an extra measure to safeguard your data: Do not sell my personal information.

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Life Insurance Quote

Request Life Insurance Quote

Blue Diamond Financial Solutions - Kevin Imhoff

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