GTM Employment Benefits, LLC

Sex:		Male    Female
	Date of Birth:	Height:	Weight:
Subscriber

How much life insurance would you like us to quote?

$50,000 $100,000 $200,000 $250,000 $500,000 $750,000 $1,000,000 $1,500,000 $2,000,000 $3,000,000 $5,000,000 $7,500,000 $10,000,000

What type of life insurance are you looking for?

20 Year Guaranteed Level Premium Term 1 Year ART (Annually Renewable Term) 5 Year Guaranteed Level Premium Term 10 Year Guaranteed Level Premium Term 15 Year Guaranteed Level Premium Term 20 Year Guaranteed Level Premium Term Universal Life Whole Life 2nd-to-die (Survivorship Insurance) Other

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 Jan Feb Mar April May June July Aug Sept Oct Nov Dec 1996 1995 1994 1993 1992 1991 Before 1990
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 driver's 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:

Additional Areas of Interest

*What product areas interest you? (please select all that apply)

Health Insurance: Short Term or Permanent Disability Insurance: Short or Long Term Dental Coverage IRA-Retirement Plans*

Inquiry Information

Please contact me as soon as possible:	Yes    No
Please send me information on health & disability insurance:	Yes    No

Even if you do not currently use GTM for your payroll needs, would you like to receive a complimentary quote?

Yes    No

How did you hear about GTM?