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Philleo Agency Insurance, Brookfield, WI

Premium Service for Your Premium Dollars

Philleo Agency Insurance
12555 W Burleigh Rd
Brookfield, WI 53005
Phone: 262-432-4200

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Life Insurance Quote Form

What is your height?*
What is your weight?*
Have you ever used any type of tobacco, chewing tobacco, nicotine patch/gum or e-cigarettes?*
- Yes
- No
If yes
- Currently use
- Stopped using over 1-year ago
- Stopped using over 3-years ago
- Stopped using over 5-years ago
Would you consider yourself to have high blood pressure?*
- Yes
- No
Are you taking a prescription for high blood pressure
- Yes
- No
Would you consider yourself to have high cholesterol level?*
- Yes
- No
Are you taking a prescription for high cholesterol?
- Yes
- no
Are you currently taking a prescription drug for a medical condition?*
- Yes
- No
Are you planning international travel in the next year?*
- Yes
- No
Are you engaged in scuba diving, hang gliding, sky diving, racing, pilot airplanes, or like activity?*
- Yes
- No
Are you currently under doctor care for any type of medical or psychology treatment?*
- Yes
- No
Have you been to a doctor in the last 5 years years for anything other than routine physical/annual exams or cold/flu like symptoms?*
- Yes
- No
Have you been admitted, over night to a hospital in the last 10 years for something other than a birth of a child?*
- Yes
- No
Are both of your parents alive?*
- Yes
- No
Did a parent die before age 60 of cancer or a heart related condition?
- Yes
- No
Have you had any speeding tickets in the last 3 years?*
- Yes
- No
Have you had any DUI, reckless driving or suspensions in the last 5 years?*
- Yes
- No
Name*
First Last
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Amount of Coverage*
- $100,000
- $250,000
- $500,000
- $1,000,000
Term*
- 10-years
- 15-years
- 20-years
- 30-years

Our Hours

Monday - Thursday 8:00 - 4:30
Friday 8:00 - 4:00
Saturday & Sunday Closed
By Appointment

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