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Baystate Brokers works with many insurance companies to ensure that you're getting the right plan at the right cost. Please review the questions below and answer as accurately as possibly. The accuracy of your initial quote depends upon the truthfulness of your answers.
Your privacy and the the security of your data is important to us. BaystateBrokers.com is a secure website to help ensure your privacy and personal information is protected.
All data is transmitted in an encrypted manner and you can rest assured that your information will be kept confidential. We only share information with our insurance partners who assist us in determining rating class or are sent an official application for processing. All data is handled and stored in compliance with state and FINRA requirements.
If the web address at the top of the page does not begin with HTTPS://, please do not enter any data. If you prefer to provide your information over the telephone, please contact us to request a meeting. |
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| The following information reflects general life insurance guidelines equal to the present value of potential future earnings which would be lost at the death of the insured. |
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View Rate Sheets: |
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| General Questions |
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| Health Questions |
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Have you ever used any form of tobacco or any nicotine product or by product? |
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| 2. |
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| 3. |
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Do you have a history of any of the following condtions? |
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Cancer |
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Cardiovascular Disease |
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Cirrhosis |
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Diabetes |
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Drug or Alcohol Abuse (no use in 10 years) |
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Has there been any indication of cancer or cardiovascular disease in your natural parents or siblings prior to their attaining age 60? |
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Have there been any deaths due to cancer or cardiovascular disease in your natural parents or siblings prior to their attaining age 60? |
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Are you currently using, or have you used, cholesterol lowering medication within the past year? |
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Have you ever been, or are you now being, treated by a medical professional for high blood pressure? |
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Are you a U.S. citizen? |
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Have you in the last 3 years, or do you intend to, reside or travel outside of the U.S.? |
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Has your license been suspended or revoked in the last 3 years? |
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Have you ever been convicted of reckless driving, driving to endanger, or driving under the influence of drugs or alcohol? |
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Except for traffic violations, have you ever been the subject of a misdemeanor or felony? |
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Have you in the last 3 years engaged in, or do you intend to engage in, any hazardous activities or sports such as |
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Hang gliding |
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Flying an airplane |
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Hot air ballooning |
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Mountain, rock climbing |
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Scuba diving |
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Sky diving or parachuting |
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Racing motor bikes |
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Are you, or do you intend to become, a member of the Armed Forces, including Reserves? |
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Are you now taking, or have you been advised to take any medications? |
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Please provide details for any Yes answers below: |
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Additional comments, questions or requests: |
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How did you find out about BaystateBrokers.com? |
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Enter the code shown above:
If you cannot read the numbers above, click Reload to generate a new one.
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Processing...
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