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Keystone Brokerage Services, LLC(dba URINSURED.COM)
URINSURED.COM P.O. Box 966, Glenside, Pennsylvania 19038

Specializing in Impaired Risk Life Insurance,
Disability & Long Term Care Planning

To receive more information about Life Insurance Coverage for someone who is a
Recovering Alcoholic, please use one of the following methods:

  • Note:It is very important that you do your very best to provide accurate information. The more accurate the information is the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

    * Name of Proposed Insured
    * Street Address
    * City
    * State of Residence
    * Zip Code
    * Daytime Phone
    * Evening Phone
    * E-mail Address
    * Date of Birth
    * Do you smoke? (Yes or No)
    * What is your gender?
    * Height/Weight

    Amount of coverage desired:

    Type of product that you are interested in:

    Alcoholism Related Questions

    Abstained from alcohol?
    Date of last drink?
    Reason for stopping?
    Number of relapse, if any?

    Current lifestyle?

    Is proposed insured a member of AA or any organized rehabilitation group? If so, please provide details?

    Has the proposed insured undergone any other type of therapy or ever been hospitalized? Please provide details.

    Any traffic violations or legal problems due to alcohol use? If so, please provide details

    Any residual damage (i.e. memory loss or liver damage)? If yes, what type and when diagnosed?

    Are blood studies normal? If no, where can we obtain a copy of the results?

    Is proposed insured taking antabuse? If yes, how long and provide details.

    Ever treated for drug problems? If so, when and provide details.

    Proposed insured's exercise habits?


    Family History
      AGE, IF LIVING STATE OF HEALTH,
    OR CAUSE OF DEATH
    AGE AT DEATH
    Father
    Mother
    Brother(s)
    Sister(s)

    Please click the submit button.

    Privacy Policy: We will never sell or otherwise knowingly distribute your contact information to any third party unless authorized by you to do so. You will not be contacted by phone, mail or e-mail unless you initiate the contact.

    *NOTE* - Submission of this form is neither an application for insurance coverage nor a guarantee of insurance coverage.

    Thank you.


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