Provide the information requested below to  initiate an evaluation of your life insurance needs.  We will contact you ASAP thereafter to discuss with you the options available. OR, simply provide us with your NAME, TELEPHONE NUMBER and EMAIL ADDRESS and we will contact you to initiate the process that will lead us to find the life insurance policy that meets you personal and finanical goals.

First Name:
Last Name:
Telephone Number:
Email:
Date of Birth:
Gender: MaleFemale
State of Residence:
U.S. Citizen:
Green Card Holder:
YesNo
YesNo
Height:
Weight:

Have you lost (significant amount of) weight in the past 12 months?


YesNo
If YES, please give details:
Do you now smoke?
Have You Ever Smoked or used any tobacco products?
YesNo
YesNo
If YES, please give details:
Please list medications taken now, or indicate NONE if applicable:
Have you had any health problems that were treated with medication or surgery for which you are not being treated now? YesNo
If YES, please give details:
Have your parents or siblings had, or have now, significant health issues? YesNo
If YES, please give details:
In the past 5 years have you had more than 2 moving violations and/or DUI’s: YesNo
If, YES, please, give details including outcome:
In the past year, have you traveled outside the country for more 3 months? YesNo
If YES, give dates and countries:
Have you ever filed for bankruptcy? YesNo
If YES, please, give DATE FILED and DATE DISCHARGED:
Have you ever had any life insurance policy rated or declined? YesNo
If YES, please, give DATE FILED and DATE DISCHARGED:

Please enter the characters below.

PLEASE CLICK ON “SEND”, UPON COMPLETION.
YOU WILL RECEIVE A CONFIRMATION E-MAIL AND, SHORTLY THEREAFTER, A FOLLOW-UP CALL FROM ONE OF OUR LICENSED LIFE INSURANCE AGENTS. THANK YOU!

OSCAR G. SURIS

Florida-Licensed Life, Health and Variable Annuity Agent

Toll Free Number: (888) 950-8376

Office Number: (786) 353-2528