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Chas. F. Hartshorne & Son, Inc.
3 Chestnut Street
Wakefield, MA 01880
781-245-4300
info@hartshorneins.com
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By completing and submitting this form, you agree hat no coverage is bound and no policy is in effect until you are contacted by one of our agency representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible, please complete all areas that apply.
 
General Information
Full Name
Email Address required
Address
City
State
ZIP Code
Telephone
Date of Birth (mm/dd/yyyy)
Use Tobacco Yes       No
Gender Male      Female
Height feet    inches
Weight  
Life Insurance Information
Type
Amount of Death Benefit
Medical Information for Life Insurance
Describe any pre-existing
health conditions
List any medications,
including dosage and frequency
Note any other pertinent information
 or requests for coverage

 
Health Insurance Information
Spouse to be insured? Yes   No
Spouse Date of Birth (mm/dd/yyyy)
Spouse Use Tobacco? Yes   No
Spouse Gender Male  Female
Spouse Height  feet  inches
Spouse Weight pounds
Children? Yes   No
Child(ren) Information
 
Date of Birth (mm/dd/yyyy)             
Gender:   Male   Female
Date of Birth (mm/dd/yyyy)             
Gender:   Male   Female
Date of Birth (mm/dd/yyyy)             
Gender:   Male   Female
Medical Information for Health Insurance
Describe any pre-existing health conditions
List any medications,
including dosage and frequency
Note any other pertinent information
 or requests for coverage

 
Disability Information
Occupation
Duties
Earnings $    Weekly    Monthly   Annually
Other Disability Coverage? Yes    No
  If yes, what type?  Individual   Group
Benefits to be Quoted STD LTD
Elimination Period
Percentage Payable
Maximum Monthly Benefit $ $
Duration of Benefits
Medical Information for Disability Insurance
Describe any pre-existing health conditions
List any medications,
including dosage and frequency
Note any other pertinent information
 or requests for coverage

 
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last updated on Friday, March 02, 2012