Life Insurance Quote

Get life insurance pricing online. To help us supply you with the best life insurance quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
 Your name:
First:
Last:
E-mail address: 
Phone numbers: 
Daytime:
Evening:
Fax:
How would you prefer to be contacted regarding your quote? 
If you would prefer to be contacted by phone,  please let us know the best time to call.
Address: 
City: 
State: 
Zip code: 
Social Security number:
Occupation:
Date of birth:
Sex:
Height: 
Weight: 
GENERAL QUESTIONS
Are you a citizen of the United States? 
Have you lived outside the United States 
during the last 3 years? 
Do you plan to leave the United States for travel or
residence during the next 3 years? 
Please list the foreign countries that you are
planning to visit / reside:
Do you currently work in a hazardous occupation? 
Do you participate in any risky outdoor activities?
Do you fly as a pilot, co-pilot
or crewmember of an aircraft?
Are you an active member of the
military or military reserve?
Have you received three or more moving violations or had your driver's license suspended/revoked in the past 5 years? 
Have you been found guilty of reckless driving
or driving under the influence (DUI/DWI)? 
When was the last time that you used any type of
tobacco product or nicotine substitute? 
Is there any family history of cardiovascular disease
before the age of 60? 
Have you had any health symptoms or been treated for any of the conditions listed below? 

If Yes, please check those below which apply:









Do you have cancer
If yes, specify cancer details here:
COVERAGE INFORMATION
Coverage Amount
Desired Term Period
Do you want an umbrella quote? 
Additional information: Leave Blank to Submit the Form.

Independent insurance agency
serving Massillon, Canton, and Stark County since 1874.

Call Toll Free:
1.800.852.7276