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Black Fox International
Special Risk Insurance Brokers
1.800.877.2445 /  610.461.6690  / Fax 610.586.5467
Contact Form


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Black Fox International, Inc.
P.O. Box 1187
Sharon Hill, PA  19079
Toll Free: 800-877-2445
Ph: 610-461-6690
Fax: 610-586-5467
Contact Us


We have the experience to save you thousands and get you the coverage that meets your needs. Call us now, we will gladly help you. 800-877-2445 / 610-461-6690



Epilepsy - Impaired Risk / Special Risk / High Risk Insurance Coverage

Any Questions? Call now, or click here to contact us. We will gladly help you. 800-877-2445 / 610-461-6690.

To receive more information about Life Insurance Coverage for someone who has
Epilepsy, please fill out the form below:

Note: It is very important that you do your very best to provide accurate information. The more accurate the information is the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

* Name of Proposed Insured
* Street Address
* City
* State of Residence
* Zip Code
* Daytime Phone
* Evening Phone
* E-mail Address
* Date of Birth
* Do you smoke? (Yes or No)
* What is your gender?
* Height/Weight

Amount of coverage desired:

Type of product that you are interested in:

Epilepsy Related Questions

What type and character (grand mal, petite mal, partial or focal)?

The dates of the first and last attacks?

The number of attacks per year? The frequency of attacks?

What type of treatment?

What type of medication and dosage?

What is the proposed insured's occupation? Is the applicant capable of driving a car?

What are the proposed insured's exercise habits?


Family History
  AGE, IF LIVING STATE OF HEALTH,
OR CAUSE OF DEATH
AGE AT DEATH
Father
Mother
Brother(s)
Sister(s)

Please click the submit button.

Privacy Policy: We will never sell or otherwise knowingly distribute your contact information to any third party unless authorized by you to do so. You will not be contacted by phone, mail or e-mail unless you initiate the contact.

*NOTE* - Submission of this form is neither an application for insurance coverage nor a guarantee of insurance coverage.

Thank you.

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Privacy Policy: We do not disclose any information that you decide to provide for use in mailing lists, surveys, or any other purpose other than what is required to perform our services.