Jim Lively Insurance
Jim Lively Insurance
When you're serious about insurance
  Proudly serving all of
  West Virginia with offices
  located in...

Jim Lively Jr. - President

Free Online Business Quote

 General Information
City:   State:    ZIP:
County:   Email:
Phone Day: ( ) -            Night: ( ) -
Best time to call:

 About Yourself
Date of Birth Sex  Marital Status  Occupation Height Weight Do you smoke?
  M   F M   S     ft   in  lbs Y   N

Have you have had any of the following health conditions:
 Heart     Cancer     Diabetes     HBP

Are you currently on any prescription medications for ongoing health conditions?
Yes   No     If yes, please list:

Please DISCLOSE any and all health conditions you have (or had in the past):

LIFE Coverages
Please select if interested in LIFE coverage.

Amount of Coverage (self): $
Amount of Coverage (dependent): $
Type of Coverage: Term 5 years
Term 10 years
Term 15 years
Term 20 years
Permanent Insurance? Y   N
Disability Income Insurance
    Income Protection
    Monthly benefit requirement:
Long Term Care Ins.
    Convalescent Care
    Daily benefit amount:
HEALTH Coverages
Please select if interested in HEALTH coverage.

Family/Individual Health Insurance
Medical Savings Accounts


Current insurance coverage description:

Would you like Information about
Annuities/Retirement Planning?
Y   N

 Additional Comments
Please give any additional comments about the coverage you desire:


531 Jones Avenue
PO Box 1633
Oak Hill WV 25901

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1-800-678-7842 | insurance@jimlively.com
2010 Jim Lively Insurance