Don Wright Insurance Agency 1500 Brittmoore Rd, Ste 301
Houston, TX 77043
Phone: 713-465-3200
eMail: sales@donwright.net
 




Home
Mission
Products
Quote
Contact
Resources










1500 Brittmoore Rd., 301
Houston, TX 77043
Phone: 713-465-3200
eMail: sales@donwright.net


Find us on:


   
 


Life Insurance Rate Class Estimator

 
To Help determine the correct rate classification,
please fill out the form below

and when completed, press the submit button.
Thank You.
Name: Date of Birth    
Male Female
Height
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 
charges?
Are you a private pilot and/or do you participate in
hazardous sports, other than recreational scuba
diving not exceeding 60 ft?
Yes             No  


 
  Home Page || Our Mission || Products || Contact Information || Quotations || Site Map || Resources
Webpage Design by Don Wright Enterprises Copyright © 2008 - 2018