-> Mergers & Acquistions -> Get an Agency Evaluation -> Billing & Online Payments Term, Universal, Mortgage Life Insurance Quote First & Last Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   Self Name: Date of Birth Sex: Marital Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Spouse Name: Date of Birth Sex: Marital Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Children Name: Date of Birth Amt. of Coverage $ Type of Coverage Term Whole Universal Term Whole Universal Term Whole Universal Additional Comments: Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentially viewed by unauthorized others. We will only use this information for insurance quoting purposes and not distribute to other parties. Image Validation: Please enter the characters in the image to the right. All letters are lowercase. Characters: ©2005 Copyright Dimond Bros. Agency, Inc. All Rights Reserved   Headquarters: 111 Sheriff St., P.O. Box 1090, Paris, IL 61944 217-465-5041 voice / 217-463-3809 fax home  about us /privacy  personal  commercial  quotes  customer support  questions?  locations  news  claims  claims reporting