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Impaired Risk: Asthma - Hepatitis - Stroke - Substance Abuse - Addictions - Excssive Prescriptions - Liver Enymes - Diverticulitis
 

Our online quotes will accurately put you in the “ball park” but ultimately you will choose from insurance plans that are customized to your personal lifestyle and medical history. Be specific about what your impaired risk is:

High Blood Pressure * Asthma * Hepatitis * Stroke * Substance Abuse * Addictions * Excessive Prescriptions * Elevated Liver Enzymes * Diverticulitis: GET THE IMPAIRED RISK SPECIALIST, ShopTermQuotes.Com to guide you through the maze and GET APPROVED! NOT DECLINED!!!! We know how to frame your condition so that it is best understood by underwriters so that they may make an informed assessement of your personal medical history. Call us now at 1-800-264-8114 or email the head of our Impaired Risk Insurance Department,Email: Tim Mouton: tmouton@shoptermquotes.com

One of our experienced, professional, licensed agents will contact you within 24 hours to discuss your options and help you choose an affordable plan that is right for you. If you are ready now, call us toll free at 1-800-264-8114.

When purchasing insurance through Shop Term Quotes Insurance Services,
you are investing in your peace of mind.

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We are your Impaired Risk Specialist!

 
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Underwriting Questionnaire For Most Impaired Risk
 
Personal Information
First Name:
Last Name :
State : Daytime Phone:
Date of Birth : mm dd yy Evening Phone:
Gender : Male Female Cell Phone:
Height: Best Time to Call:
Weight (lb): Email:
Coverage Information
Tobacco: Yes No
Type of Tobacco:
How much?
Amount of Insurance:
Type of Insurance:
Have you previously been declined for insurance? Yes No
Which Company?
Health Information
Do you have high blood pressure? Yes No
Systolic Rating: Diastolic Rating:
Do you have high cholesterol?  Yes No
Cholesterol: HDL Ratio:
Family history (Parents, Siblings) of cancer or heart disease? Yes No
Parent Age of Diagnosis: Age of Death:
Siblings Age of Diagnosis: Age of Death:
Health Conditions
Cancer Alcoholism Alzheimer's
Depression Heart Disease Sleep Apnea
Diabetes Hepatitis Liver Disease
Rheumatoid Arthritis Stroke Parkinson's
Kidney Disease Leukemia

Other Details: Please be as specific as possible or call us now 1-800-264-8114

WE HAVE SUCCESSFULLY OBTAINED COVERAGE FOR THOSE PREVIOUSLY DECLINED!

Hazardous Activities
Activities Details:
Aviation

Scuba Diving

Other
Moving Violations, DUI: Yes No Details:
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