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Independent Insurance Agent

Life / Health Insurance
Quote Form

When filling out the Life / Health Insurance Quote Form below, be sure to fill in all of the Information in the Blue Sections. If you do not fill out this required information, your form will not be processed.

Mathes Insurance Group is licensed to sell insurance in the State of Iowa. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will be unable to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Mathes Insurance Group accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.


General Information

Name:

Address:

City:

  State:    ZIP:

County:

  Email:

Evening Phone:

( )           

Day Phone:

( )

Best time to call:

  am  pm

About Yourself:

Date of Birth

Sex

 Marital Status 

Occupation

Height

Weight

Do you smoke?

   

M   F

M   S

   

  ft   in 

lbs

Y   N

Have you have had any of the following health conditions:
Heart     Cancer     Diabetes     HBP

Are you currently on any prescription medications for ongoing health conditions?

Yes   No     If yes, please list:

Please DISCLOSE any and all health conditions you have (or had in the past):

About Your Spouse (Only if he or she is to be covered):

Name

Date of Birth

Sex

Occupation

Height

Weight

Do you smoke?

 

M   F

   

  ft   in 

lbs

Y   N

Have they any of the following health conditions:
Heart     Cancer     Diabetes     HBP

Are they currently on any prescription medications for ongoing health conditions?

Yes   No     If yes, please list:

Please DISCLOSE any and all health conditions they have (or had in the past):

Coverages
Please select the following coverages:

LIFE Coverages

Please select if interested in LIFE coverage.

Amount of Coverage (self):

$

Amount of Coverage (spouse):

$

Type of Coverage:

Term
Whole
Universal

Disability Income
Coverage?

Y   N

Long term care
coverage?
 

Y   N

Coverage for:

Self
Spouse

HEALTH Coverages

Please select if interested in HEALTH coverage.

High deductible
catastrophic plan:

Y   N

No deductible co-pays:

Y   N

Maternity:

Y   N

Mental Health:

Y   N

Chiropractic:

Y   N

Acupuncture:

Y   N

Dental:

Y   N

Vision:

Y   N

Preventative:

Y   N

Coverage for:

Self
Spouse

Additional Comments:

Please give any additional comments about the coverage you desire:

 

Thank you for your time in submitting this
Life / Health Insurance Quote Form.
One of our representatives will respond to your
submission as soon as possible!

Mathes Insurance Group
120 W. State Street
Mason City, Iowa 50401		 Phone: 641-423-4663
Toll Free: 877-421-4663
E-Mail: rickmathes@rickmathes.com