Life Quote in York County, Pennsylvania 1st Person Name Address Person 1 DOB Person 1 Height Person 1 Weight Person 1 Tobacco Use Smoker Non-smoker Smokeless Tobacco Vape Email Person 2 Spouse's Name Person 2 DOB Person 2 Tobacco Use Smoker Non-smoker Smokeless Tobacco Vape Person 2 Height Person 2 Weight 1) Existing conditions & medicine/YOU Diabetic? Yes No A1C level When were you diagnosed? Life insurance now? YES NO Insurance Amount Type Term Whole Universal Type Insurance Requested Term Whole Universal Request Amount 2) Existing conditions & medicine/SPOUSE If diabetes need AIC # how long have you had condition? Life insurance now? Current Amount Insurance Type Term Whole Universal Type Insurance Requested Term Whole Universal Amount Do you want children? YES NO Children details Would you like quotes for your child(ren)? YES NO Dependent's Name Dependent's DOB Dependent's Health Issues Consent By checking this box, I consent to receive SMS/Text messages related to Customer Care from FEESER INSURANCE INC. You can reply "STOP" at any time to opt-out. Message and data rates may apply. Message frequency may vary, reply "HELP" to 717-767-1070 for assistance, and learn more on our Privacy Policy and SMS Terms and Conditions pages Current Coverage Submit
