Δ
We write in New York only.
www.EmpireSafetyCouncil.com/HILL
MaleFemale
SingleMarried
TermWhole LifeVariable LifeUniversal LifeUnsure
The applicant has been treated by a physician in the past 12 months (excluding voluntary annual check ups, pap smears, minor colds and flu, etc) The applicant has been hospitalized in the past 5 years (excluding pregnancy) The applicant has been receiving ongoing medical treatments (excluding regular pap smears, voluntary check-ups, etc) The applicant smokes or uses another form of tobacco The applicant participates in racing, sky diving, hang gliding, mountain climbing or other hazardous activities or occupation(s) Any Other
HIV/AIDS Heart Attack Stroke Diabetes High Blood Pressure Depression Requiring Medication Cancer Asthma Other Major Illness
Employed Retired Student Government Homemaker Unemployed Military
YesNo
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
Yes, I Agree.