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John W Collier, LUTCF, FSS
NVSilver Life & Health Insurance agency
(775) 829-1221




    Basic Quote Information:
    • State of Residence:
    • Guaranteed Term:
    • Coverage Amount:
    • Payment Mode:
    Information About
    The Proposed Insured:
    • Gender:Male  Female
    • Date of Birth: e.g. MM/DD/YYYY
    • Height / Weight: /  lbs.
    Tobacco:Have you ever used tobacco products?Yes  No

    Check products you have smoked or used:
    •  Cigarettes
      • How long has it been since you last smoked a cigarette?
      • On average, how many cigarettes did you smoke per day?
    •  Cigars
      • How long has it been since you last smoked a cigar?
      • On average, how many cigars did you smoke per month?
    •  Pipe
      • How long has it been since you last smoked a pipe?
    •  Chewing Tobacco
      • How long has it been since you last used chewing tobacco?
    •  Nicotine patch or gum
      • How long has it been since you last used a nicotine patch or gum?
    Blood Pressure Information:Have you ever been treated for high blood pressure?Yes  No
    • What is your systolic pressure?
    • What is your diastolic pressure?
    • When were you last treated for high blood pressure?

    • If currently taking blood pressure medication:
    • How long has your blood pressure been successfully controlled by
      medication?
    Cholesterol Information:Have you ever been treated for high cholesterol?Yes  No
    • What is your cholesterol level?
    • What is your HDL ratio?
    • When were you last treated for high cholesterol?

    • If currently taking cholesterol medication:

    • How long has your cholesterol been successfully controlled by medication?
    Driving History Information:Have you had your license suspended or revoked, or had more than one ticket or accident in the past 5 years?Yes  No
    • Have you ever been convicted of drunk driving DUI/DWI? Yes  No
      • How long since the most recent DUI/DWI conviction?
    • Have you ever been convicted of reckless driving? Yes  No
      • How long since the most recent conviction for reckless driving?
    • Have you ever had your license suspended/revoked? Yes  No
      • How long since the most recent conviction resulting in a revoked or suspended license?
    • Have you ever had more than one accident? Yes  No
      • Not counting your last accident, how long has it been since the accident which preceded your last?
    • Please indicate the TOTAL number of moving violations/tickets (not parking tickets) that you have received in each of the last time periods:
      • during the last 6 months:
      • during the last 1 year:
      • during the last 2 years:
      • during the last 3 years:
      • during the last 5 years:
    Criminal History Information:Are you currently on parole or probation OR have you ever been convicted of a misdemeanor or felony?Yes No 
    Health History:Have you ever been treated for any of the following medical conditions?
    (Check any that apply)
    •  Alcohol/Drugs
    •  Alzheimer's Disease
    •  Asthma
    •  Basal Cell Skin Cancer
    •  Cancer
    •  COPD
    •  Crohn's Disease
    •  Depression
    •  Diabetes
    •  Epilepsy
    •  Emphysema
    •  Heart Disease
    •  Kidney or Liver Disease
    •  Mental Illness
    •  Multiple Sclerosis
    •  Rheumatoid Arthritis
    •  Sleep Apnea
    •  Stroke
    •  Ulcerative Colitis or Ileitis
    •  Vascular Disease
    Avocation Information:Do you participate in any hazardous activities like racing or motor sports, hang gliding, piloting, rock climbing, scuba diving, or sky diving?Yes  No
    Family History Part A:Family Related Death
    Please indicate the total number of family members (parents or siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
    • Youngest Family death due to disease (Father, mother, brother or sister)
      • Please indicate the age of the youngest family member who died due to an illness:
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma
    • 2nd youngest Family death due to disease (Father, mother, brother or sister)
      • Please indicate the age of the 2nd youngest family member who died due to an illness:
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma
    • 3rd youngest Family death due to disease (Father, mother, brother or sister)
      • Please indicate the age of the 3rd youngest family member who died due to an illness:
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma
    Family History Part B:Family Related Occurence of Disease
    Not including those who died, please indicate the total number of family members (parents or siblings) who have contracted a cardiovascular disease (heart attacks and strokes), cancer, diabetes, or kidney disease before the age of 70:
    • Youngest family member to contract disease (Father, mother, brother or sister)
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma
    • 2nd youngest family member to contract disease (Father, mother, brother or sister)
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma
    • 3rd youngest family member to contract disease (Father, mother, brother or sister)
      • Please indicate the age when this person first contracted illnesses:
      • Was this person a parent?
      Please check off any and all illnesses which this family member experienced:
      •  Cardiovascular Disease CVD
      •  Coronary Artery Disease CAD (or Heart Attack)
      •  Cardiovascular Impairments
      •  Cerebrovascular Disease CVA (or Stroke)
      •  Diabetes
      •  Kidney Disease
      •  Colon Cancer
      •  Intestinal Cancer
      •  Breast Cancer
      •  Prostate Cancer
      •  Ovarian Cancer
      •  Other Internal Cancer
      •  Malignant Melanoma
      •  Basal Cell Carcinoma

    John W Collier, LUTCF, FSS / NVSilver Life & Health Insurance agency, is a licensed life insurance agent. The following agent license numbers are provided for John W Collier, LUTCF, FSS / NVSilver Life & Health Insurance agency as required by state law: CA agent #0806547, CO agent #393869, NV agent #27257, OR agent #153203. Commercial use by others is prohibited by law. This site provides life insurance quotes. Each rate shown is a quote based on information provided by the carrier. No portion of this website may be copied, published, faxed, mailed or distributed in any manner for any purpose without prior written authorization of the owner.