Affinity Insurance Agency, Inc.
Premium Estimate Life

PREMIUM ESTIMATE LIFE
Name:
Address:
Email:
City:   State:   Zip :
Phone:   Fax:
Date of Birth:  Gender:  Smoke/Tobacco : Yes     No

Amount of Insurance :

Desired Length: Circle the one below that applies to you.
Guaranteed: 5yrs    10yrs     15yrs 20yrs     Age 100
Term: 5yrs     10yrs       15yrs 20yrs    25yrs    30yrs
Return of Premium: 15yrs       20yrs 30yrs

Health Classification: Circle the one below that applies to you.
          Regular – Average Health                  Regular Plus – Better than Average Health
Preferred – Excellent Health                 Preferred Plus – Superior Health
Comments:

Phone: 770-974-5502
Fax: 770-974-5359
Mail: mklocke@profliability.com 		3950 Cobb Parkway, Suite 707
Acworth, GA 30101