Alan Hilling: Independent Insurance Agent, Erie PA

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Name:
Address:
City:	State: Zip:
Current Career:
Type of Business:
Current Policy Expires:	/ / (Month/Day/Year) (Leave blank if no current policy.)
Daytime Phone:
Evening Phone:
Fax Number:
Email:
Best time to Contact:
Sex:	Male Female
Date of birth:	/ / (Month/Day/Year)
Height:	Feet Inches
Weight:	Pounds
Amount?
Type of life insurance?

   Description of other type of coverage you are looking for:
     The coverage to be quoted will likely be:
     New coverage (I have none now)    Additional coverage
     Replacement of existing coverage
  Tobacco Usage
     I have never smoked.
    I used to smoke, but I quit in
     I smoke no more than one pack of cigarettes per day.
     I smoke more than one pack of cigarettes per day.
     I smoke cigars. I smoke a pipe. I chew tobacco.
     I am on "the Patch."
  Do you take any prescription medication?
     Yes   No
  If yes please explain.      Do you have any health problems?
   Yes   No.
  If yes please explain.

  Are you a private pilot?
   Yes   No.
  If yes, please explain type of rating, type of aircraft,
  total number of hours experience, and hours flown per year:
     Do you engage in scuba diving, sky diving, rock climbing,   motorized racing, or other hazardous avocation or occupation?
   Yes   No
  If yes, please explain in detail:
     Have you been convicted of drunk driving, or had your drivers
  license suspended or revoked in the past five years?
   Yes   No
  If yes, please explain in detail:
     Have you been convicted of three or more moving violations in the
  past three years?
   Yes   No
  Have you ever been convicted of a felony?
   Yes   No
  If yes, please explain dates, charges, and details:
     In the past 10 years, I have been advised regarding,
  or been treated for:
   Hypertension   Heart Disease   Cancer   Diabetes
   Stroke   Alcohol or Drugs    AIDS   Other
  If you checked any of the above, please explain:
     Did any of your grandparents, parents or siblings have heart
  disease or cancer, prior to age 65?
   Yes   No.
  If yes, please explain:

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