Rosenthal Bros, Inc.

Creative Solutions
for Business.

Individual Life Insurance

If you would like a quote on your life insurance, please complete the form below. Someone will contact you as soon as possible. All information provided will be received directly by our agency and will remain confidential.

Name

Home Phone

Email Address

Gender

Date of Birth

Smoker or Non-snoker?

Yes No

Date of last cigarette

Medical Conditions

Current Medications
(include dosage):

Height

Weight

Type of Plan Desired
(mark all that apply):

Term Return of Premium Universal
Key-man Buy-Sell Whole Other

Are you replacing coverage?

Yes No

Why?

Do you currently have life insurance policies in force that will not be canceled?

Yes No

Annual Income

Need for insurance

Family History
Father
Age if Living
Age at Death
Cardiac Conditions or Heart Disease?	Yes No
If yes, date of onset
Cancer History?	Yes No
If yes – Type and Date of Onset?

Mother
Age if Living
Age at Death
Cardiac Conditions or Heart Disease?	Yes No
If yes, date of onset
Cancer History?	Yes No
If yes – Type and Date of Onset?