Don Wright Insurance Agency 1500 Brittmoore Rd, Ste 301
Houston, TX 77043
Phone: 713-465-3200


1500 Brittmoore Rd., 301
Houston, TX 77043
Phone: 713-465-3200

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Life Insurance Rate Class Estimator

To Help determine the correct rate classification,
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Name: Date of Birth    
Male Female
Feet Inches Weight
Do you currently use or have you ever used
tobacco and/or nicotine products?
Have you ever been told by a medical professional
that you have high blood pressure?
Are you currently being or have you ever been
treated for alcohol or drug use?
Do you have any other known significant medical
conditions, such as diabetes or depression?
Yes             No  
Has any parent or sibling ever been diagnosed with
cancer, stroke, or a heart disorder prior to age 60?
Yes             No  
Has any of your parents or siblings died prior to age
60 from cancer, stroke or a heart disorder?
How many, if any, moving violations have you had
in the last 3 years?
Have you ever had any DUI or reckless driving 
Are you a private pilot and/or do you participate in
hazardous sports, other than recreational scuba
diving not exceeding 60 ft?
Yes             No  

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