Life Insurance Query
(Washington residents only)

There are a variety of life insurance policies including discounted rates for nonsmokers and those with good health histories.  Please fill out the preliminary form below to help in obtaining the appropriate policy for you.  There are no required fields, and the information is confidential.

If you prefer not to complete this form, please send us an email at insure@cio.net, or you may fax your request to 360-738-0193.  As well, you can talk to us in person by calling 800-676-0090 or 360-647-0090.


 
Name
Address 
City 
State  Zip 
Work
Phone
Home
Phone 
E-mail (enter correctly or leave blank)
Date of Birth  Have you used tobacco in any form in the last 12 months?
YesNoNever
What is your current health status? ExcellentGood FairPoor 
Do you suffer from any of the following? CancerTumor Aids or Hiv Lung Disease Respiratory Disease 
Heart Disease DiabeticHigh Blood Pressure Low Blood Pressure 
Please list any other health problems or comments
Amount of coverage

This query does not bind coverage in any way.

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Thank you for your interest!  Email us at insure@cio.net or call 360-647-0090 or 800-676-0090 for further assistance or questions.
 

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