Yardley Insurance - The people you can count on.

Life Insurance Quote Form

	Please fill out the form below:

	Name:
	Address:
	City:
	State:				Zip:
	County:
	Phone:
	E-mail:
	Date of Birth:

	Smoker:	Yes No

	Health Status:	Excellent Very Good Good

	Amount of Insurance to be Quoted:	100,000 200,000 300,000 400,000 1,000,000

	Term Requested:	5 Years 10 Years 15 Years 20 Years

	Additional Comments: