Allegro Insurance Agency
Cell 201-988-5534
1481 Oak Tree Rd.
Iselin, NJ 08830

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First Name     Last Name 
Email Address    
City          State Zip code
Phone #          SS #   
Date of birth  

Gender     Height  Ft.    In.  Weight Lbs

Desired amount of life insurance coverage
$250,000    $350,000  $500,000  Other 
Desired duration of policy coverage

Have you ever been treated for taken medication for any of the following conditions?
None                                          Alcohol or Substance abuse
Blood Pressure                            Asthma
Cancer                                       Depression, anxiety
Cholesterol                                 Diabetes
Heart problems                         Sleep apnea
Describe significant medical issues

Before they turned age 60, were your parents or siblings diagnosed with cancer, heart disease or stroke?
If yes,
Father: Cancer - Type  , Heart, Stroke, Age at death
Mother:Cancer - Type  , Heart, Stroke, Age at death
Sibling: Cancer - Type  , Heart, Stroke, Age at death

How many driving tickets for moving violations in the last 3 years? ,  5 Years?
DUI conviction If yes, date

Have you smoked cigarettes in the past 5 years?
Are you a current tobacco user? if you quit, date stopped 

Have you used any other forms of tobacco or nicotine in the past 5 years
Type of tobacco use   Frequency used

Any intended travel outside the US during the next 2 years?
If yes, where?

Do you engage in any hazardous activities including but not limited to Scuba diving, private pilot, skydiving, rock climbing...   If yes, please describe