PC Agency Help, helping to make your life sales easy! info@pcagencyhelp.com 866-BAY-PLAN (229-7526)
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	Underwriting Guidelines   Medical Examination Info   Special Risk   Life Insurance Forms   Blank Quote Form   Privacy Policy   Life Insurance Quote SPECIAL RISK Insurance Book Takes Your Privacy Seriously PCAgencyHelp.com specializes in helping our clients with medical impairments receive the best rates and policies with the highest rated insurance companies. We have twenty-two years experience in this market and will be able to help you with any questions or concerns. The first step is to complete the attached form and we will be able to get you a free quote based on your health history within twenty-four hours. Please call with questions on the West Coast at: 800-217-9800 Ext 333 or on the East Coast at: 866-BAY-PLAN (229-7526) or email us at: info@pcagencyhelp.com . *Denotes a required field PROPOSED INSURED First Name*: MI:  Last Name*: Address*: City*:  State*:  Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip*:  (Please enter at least one phone number) Home Phone: -- Work Phone: -- ext. Cell Phone: -- Birthdate*: Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 Sex*: Male Female Used Tobacco in Past 3 years?*: Yes No Email Address*: Best Time When We Should Call: Select 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 Select am pm Height:  ft.   in. Weight:  lbs. Do you currently use prescription medications?: Select yes no If yes, please indicate type and dosage in the 'Additional Information Section' Do you have any family history of cardiovascular disease or cancer in your parents or siblings, prior to age 61?: Select yes no Do you plan to replace or lapse any existing life insurance policy (does not include employer provided policies)?*: Select yes no Have you ever had or been treated for any of the following medical conditions: Cancer Diabetes Heart Disease Additional Information Section: ( You may enter up to 200 characters. )  characters left  I'm ready to apply. Please send my application package at no cost or obligation.  I want to apply but I have some questions (Please note above).