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Michael W. Smith Agency

Revised:

May 06, 2015

Critical Illness

 763-535-7293

 

 

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Critical Illness Quote Request Form

This is a request for a Minnesota critical illness insurance quote, not a policy application. Submitting this form does not obligate you to purchase any critical illness insurance products. Please complete this form as accurately as possible. Critical illness insurance rates are subject to change.

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Critical illness insurance provides a payment if you experience a critical illness that is covered under the policy contract. You don't have to be disabled to collect.  Unlike disability insurance, you don't have to be employed.

A critical illness insurance payment is typically made in a lump sum and can be spent however you please - use the money for medical bills, a wheelchair, retrofitting your home, your mortgage or other bills, home health care or even a Hawaiian vacation. Medical conditions that qualify usually include serious injuries, diseases and major surgeries.

General Information

Name
Street
City, State ZIP             
E-mail
Phone
Fax:
Send information by:

 

Birthdate Sex Tobacco Use
Height Weight

 

Do you have health problems? Describe any health problems
Yes No

 

Lump-sum Benefit
($50,000 minimum
$1,000,000 maximum)
$

 

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