Personal Insurance


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Experienced life insurance agents at Theiss Insurance Agency can assist you by designing a policy that best fits your personal or business needs. We want to help you protect those who are most important to you with the right life insurance. We offer a broad range of optional coverage throughout Harris and surrounding counties.

 

Life Insurance Products:

  • Whole Life
  • Term Life

You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.




Personal Information


Name Email Address
Address Day Phone
City Night Phone
State  Zip  Best Time to Call  
AM  
PM
Preferred Contact Method Email  
Phone

Personal Information Please enter information below for all to be covered.


 
Self
Spouse
Child #1
Child #2
Child #3
Name:
Self
Date of
Birth:
Sex:
M   F
M   F
M   F
M   F
M   F
Marital Status:
M   S
M   S
M   S
M   S
M   S
Occupation:
Height:
ft.  
in.
ft.  
in.
ft.  
in.
ft.  
in.
ft.  
in.
Weight:
lbs.
lbs.
lbs.
lbs.
lbs.
Have you (they) had
any of the following
health conditions:
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Please enter information below about TOBACCO usage for all to be covered.
Have you (they)
ever used tobacco or
nicotine products?:
Never
Present
Quit**
Never
Present
Quit**
Never
Present
Quit**
Never
Present
Quit**
Never
Present
Quit**
Type of
Tobacco used?:
smokeless
cigar
cigarette
pipe
patch/gum
smokeless
cigar
cigarette
pipe
patch/gum
smokeless
cigar
cigarette
pipe
patch/gum
smokeless
cigar
cigarette
pipe
patch/gum
smokeless
cigar
cigarette
pipe
patch/gum
Packs per day:





# of yrs smoked:
**Quit — Please enter information if any to be insured are FORMER TOBACCO users.
**Quit Month/Year:
Packs per day:
Years smoked?:

Individual Histories Please list any individual histories on each person to be covered.


Self
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):
Spouse
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #1
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #2
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):
Child #3
Is person to be insured currently on any prescription medications for
ongoing health conditions?Yes  No     If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages


 
Self
Spouse
Child #1
Child #2
Child #3
Amount of
Coverage:
$
$
$
$
$
Type of
Coverage:
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Length (Optional)
Disability
Income:
Y   N
Y   N
N/A
N/A
N/A
Long Term
Care:
Y   N
Y   N
N/A
N/A
N/A

Additional Comments



Please give any additional comments you feel appropriate for this
quotation. If you have additional children or other information where there
was not enough space, please enter them here.


Please click on the “Submit Quote” button to send your quote request.
One of our representatives will respond to your submission as soon as possible.