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Lighthouse Santa Cruz

CREATING PEACE OF MIND
SINCE 1964

Life Insurance Questionnaire

ALL INFORMATION PROVIDED ON THIS FORM WILL BE HELD CONFIDENTIALLY BY Santa Cruz Insurance Services, Inc. BY COMPLETING THIS FORM YOU UNDERSTAND THIS INFORMATION WILL BE SHARED WITH INSURANCE CARRIERS RECEIVING YOUR APPLICATION FOR INSURANCE AND THAT SCI WILL PROTECT THIS INFORMATION FROM BEING SHARED OTHERWISE.

DOB:
Month
Day
Year
Term:
Nicotine Use?:
Yes
No
Other

+ If you have minor children or young adult children, we suggest you name your Trust or your Estate as contingent Beneficiary.

*Please note: if you leave this page before hitting submit, your form will not be saved.

Interested in other coverage options or a package discount?

Earthquake Insurance
Flood Insurance
Personal Umbrella Protection
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