Life & Health Insurance Quote Form
We would like to provide you with a free, no obligation life/health insurance quote.  Please provide as much information as possible for the most accurate quote.  This information will be kept confidential and will be used for quote purposes only.

General Information
Today's Date
Name
Address
City State Zip
Day Phone
Night Phone
Best Time To Call AM PM
Email


Information About Yourself And Family
Name
Date of Birth
Sex M F
Marital Status M S
Occupation
Height
Weight
Have you had any of the following health conditions: Heart Cancer Diabetes HBP


Spouse:
Name
Date of Birth
Sex M F
Marital Status M S
Occupation
Height
Weight
Have you had any of the following health conditions: Heart Cancer Diabetes HBP


Child #1
Name
Date of Birth
Sex M F
Marital Status M S
Occupation
Height
Weight
Have you had any of the following health conditions: Heart Cancer Diabetes HBP


Child #2
Name
Date of Birth
Sex M F
Marital Status M S
Occupation
Height
Weight
Have you had any of the following health conditions: Heart Cancer Diabetes HBP


Child #3
Name
{edateofbirth title} {edateofbirth value}
Sex M F
Marital Status M S
Occupation
Height
Weight
Have you had any of the following health conditions: Heart Cancer Diabetes HBP


Individual Histories
Are you (self) currently on any prescription medications for ongoing health conditions? Y N
For yourself, please list medications here and disclose any and all health conditions you have (or had in the past):

Are you (spouse) currently on any prescription medications for ongoing health conditions? Y N
For spouse, please list medications here and disclose any and all health conditions you have (or had in the past):
Are you (child #1) currently on any prescription medications for ongoing health conditions? Y N
For Child #1, please list medications here and disclose any and all health conditions you have (or had in the past):
Are you (child #2) currently on any prescription medications for ongoing health conditions? Y N
For Child #2, please list medications here and disclose any and all health conditions you have (or had in the past):
Are you (child #3) currently on any prescription medications for ongoing health conditions? Y N
For Child #3, please list medications here and disclose any and all health conditions you have (or had in the past):


Life Insurance Coverages
Self - Amount of Life Insurance Coverage
Type of Coverage Term Whole Universal
Disability Income Y N Long Term Care Y N


Spouse
Spouse - Amount of Life Insurance Coverage
Type of Coverage Term Whole Universal
Disability Income Y N Long Term Care Y N


Child(ren)
Per Child - Amount of Life Insurance Coverage


Health Insurance Coverages
Need Health Insurance Coverage for:
High Deductible Catastrophic Plan
No Deductible, Co-Pays
Maternity Coverage
Preventative Care
Mental Health
Chiropractic
Vision
Dental
Please describe other desired coverages (not listed above) here:


Additional Comments
Please use this space to provide any additional information about your property that would be helpful with the preparation of this quote.


About Brenneis Insurance


Brenneis Insurance Agency, Inc. has been incorporated and in business in Tekamah, Nebraska since 1979.  Brenneis Insurance is a member of the The Independent Insurance Agents of Nebraska and has numerous relationships with Independent carriers and national brokers.

Kevin Brenneis, CIC is owner and principal of Brenneis Insurance Agency, Inc. Kevin has been in the insurance industry since 1996 and received his Certified Insurance Counselor designation in 2003.



  




 

Get a Quote


Brenneis Insurance Agency, Inc. is a full service agency offering many types of insurance coverage.  To be of better service to you, we have equipped this site with links for you to submit information to receive auto, home, life, disability, and health insurance quotes.    <<read more>>

If you would like to receive commercial insurance or farm quotes, you will need to contact Kevin Brenneis at the agency or send him an email with your contact information so he can gather the appropriate information.


Get a Quote here!
Click here to access our Quote Forms.



Kevin Brenneis, CIC

Kevin Brenneis, CIC is owner and Principal of Brenneis Insurance Agency, Inc. Brenneis Insurance has been in business in Tekamah, Nebraska since 1979.

Contact Us Now

Brenneis Insurance Agency

129 S. 13th Street
Tekamah, NE  68061

Phone:  402.374.1911
Mobile:  402.870.0693
Fax:        402.374.1915

Email Us

World Class Customer Service

Our office is fully staffed with trained professionals who are also licensed agents and customer service reps.  Lucille Eriksen, Kristi Gross, Sheryl Stansberry and Cathy Zink are available to help you with all of your personal insurance needs. 



 We all look forward to serving you!

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