Intermountain Insurance Agency
Intermountain Imsurance Agency
194 E Neider St. • Coeur d’Alene, ID 83815
local 208-664-6085
fax 208-457-0777
Office Hours: Mon-Fri, 8-5
GET A QUOTE ON:
Confidence in Insurance Coverage
Financial Services Personal Insurance Services
.

LIFE /HEALTH INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy. Fields with a "*" are required.
PERSONAL INFORMATION
 Your name:
First*:
Last*:
E-mail address*: 
Phone numbers: 
Daytime*:
Evening:
Fax:
Are you interested in Quote for:
Life Insurance
Health Insurance
How would you prefer to be contacted regarding your quote? 
 Phone   Fax   Mail   E-mail
If you would prefer to be contacted by phone,
 please let us know the best time to call.
 AM   PM
Address: 
City: 
State: 
Zip code: 
Occupation:
Date of birth:
Sex:
Height: 
Weight: 
GENERAL QUESTIONS
When was the last time that you used any type of
tobacco product or nicotine substitute?
Any pre-existing conditions? 
 Yes No
If yes, please comment: