Please complete and submit the following quote to Comprehensive Benefit Services, Inc.
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Best time to contact you:
Daytime
Evening
Best place to contact you:
Home
Work
Sex:
Male
Female
Date of birth:
/
/
(mo/day/yr)
Your Height:
Feet Inches
Your Weight:
Pounds
How much life insurance would you like us to quote?
The coverage to be quoted will likely be:
new
coverage (I have none now)
additional
coverage
replacement
of existing coverage
Tobacco Usage:
I have never smoked.
I used to smoke, but I quit in
I
smoke no more than one pack of cigarettes per day.
I
smoke more than one pack of cigarettes per day.
I smoke
cigars.
I smoke a
pipe.
I chew
tobacco.
I am on "the
patch."
Do you take any
prescription medication?
Yes
No
If yes, please explain:
Have you been
convicted of drunk driving, or had your driver's license suspended
or revoked in the past five years?
Yes
No
If yes, please explain in detail:
In the past 10 years, I have been advised regarding or been treated for:
Hypertension
Heart
Disease
Cancer
Diabetes
Stroke
Alcohol
or Drugs
AIDS
Other
If you checked any of the above, please explain:
Any other questions or comments:
Lee V. Bethel is securities licensed in the following states: AL, AZ, CO, DC, DE, FL, GA, IL, IN, MD, NY, OH, OK, PA, SC, TX, and VA. Lee V. Bethel is insurance licensed in the following states: VA, MD, DC, PA, IL, CT, OH, and OK. For Securities Information, click here. Securities offered through Linsco/Private Ledger, Member FINRA/SIPC.
