Life Insurance Questionnaire

Please answer the following questions so we can help you find the best policy to suit your needs.

Name(Required)

First Last

Email Address(Required)

Phone Number(Required)

Address

Street Address Address Line 2 City State / Province / Region

ZIP / Postal Code(Required)

County(Required)

Date(Required)

Height(Required)

Weight(Required)

How much life insurance would you like us to quote?(Required)

$25,000-$100,000

$100,000-$250,000

$250,000-$500,000

$500,000-$750,000

$1,000,000+

I am not sure

What type of life insurance are you looking for?(Required)

10 Year Term

15 Year Term

20 Year Term

Permanent

Accidental Death / Non-Medical

I am not sure

Coverage to be quoted will likely be:(Required)

New Coverage (no current coverage)

Additional Coverage

Replace Existing Coverage

Health History

Do you use tobacco?(Required)

Yes

If yes, please explain your tobacco usage. How often and what kind(s)?

In the past 10 years, I have been advised regarding or been treated for (check all that apply)

Hypertension

Cancer

Alcohol

Heart Disease

Diabetes

None of the above

If yes, please explain.

Do you take any prescription medication?(Required)

Yes

If yes, please explain.

Do you engage in any hazardous activities such as private piloting or scuba diving?(Required)

Yes

If yes, please explain.

In the past 10 years, have you had any DUI's or have you had more than 2 moving violations in the past 3 years?(Required)

Yes

If yes, please explain.

Have you ever been convicted of a felony?*(Required)

Yes

If yes, please explain.

In the past 5 years have you filed for bankruptcy?*(Required)

Yes

If yes, please explain.

Name

This field is for validation purposes and should be left unchanged.

Jon Nolan Insurance

We extend coverage to individuals and businesses in 4100 Alpha Rd Suite 472 Dallas, TX 75244 and surrounding areas.

Phone: (469) 205-6888

Email: jon@jonnolaninsurance.com

Office Hours:
Monday to Friday: 8 am to 5 pm
After hours:
Saturday & Sunday - By phone or appointment

Insurance

Medicare

Health Insurance

Life Insurance

Supplemental Insurance

Know More

Jon Nolan Insurance offers a wide range of insurance plans across Texas, including Medicare Supplement (Medigap), Medicare Advantage (Part C), Prescription Drug Plans (Part D), individual and group health insurance, life insurance, as well as dental and vision coverage. We proudly serve cities like Dallas, Fort Worth, Arlington, Plano, Frisco, Denton, McKinney, Irving, Garland, Coppell, and Rockwall—covering counties including Dallas, Tarrant, Collin, Denton, Ellis, Johnson, Kaufman, Parker, and Rockwall.
Not affiliated with or endorsed by the U.S. government or the federal Medicare program.