MaheuInsurancD29aR03aP01ZL[1].jpg                                                        

 

172 Union Ave. Laconia, NH 03246 

  (603) 524-0753 

 

Please include as much information as possible so we can give you an accurate quote, or just fill in your name, phone number and email address and we will contact you.

Fields marked with * are reqired.

First, tell us about you.

First Name:*
Last Name:*
Phone Number *
E-mail Address:*

Mailing addtess

PO Box or Street
City, State Zip

Physical Address

Street address
City, State Zip
Date of birth
What is your gender?

Social Security Number
Relationship Status
Height Feet
Height Inches
Weight
Occupation
Do you smoke or use any other form of tobacco?

Do you totally abstain from alcohol?

Have you been treated by a physician in the past 12 months? (excluding voluntary annual check ups, pap smears, minor colds & flu, etc.)

Have you been hospitalized in the past five years? (excluding pregnancy)

Are you currently taking any prescription medications? (excluding voluntary prescriptions such as Viagra, diet pills, vitamins, mineral supplements, calcuim, or oral contraceptive)

Are you receiving any ongoing medical treatments? (excluding regular pap smears, voluntary check ups, etc.)

Do you participate in racing, sky diving, hand gliding, mountain climbing, or anyother hazardous activity or occupation?

Have you been diagnosed with any of the following:







Type of Insurance Desired
Death Benefit (Minimum Policy Amount $50k)
To prevent spam, please tell us:
What is six plus nine?*
Powered by liveSite Get your free site!