Please complete this form:

Health Insurance Fact Finder:

Last Name:    First Name:

Address:    

City:          State:     Zip

Email:       

Phone:      

Date of Birth:    

Name of Current Carrier:      

Current Coverage Information:    Deductible $ Office Copay $

Coverage:

Single

You & Your Spouse

You & Your Child(ren)

Family     Spouse's Age    # of children

Do you smoke? [ Yes]   [ No] 

Does anyone to be covered have any significant ongoing medical conditons including pregnancy?

Yes No

If yes, please describe:

Does anyone covered have to take any medications?

Yes No   If yes, please describe:

If you would like a Long-Term Disability quote, please provide the following additional information:

Job Title

Annual Income $

Waiting period desired before benefits begin:

30 days 60 days 90 days 180 days   360 days

If you would like a Life Insurance quote, please provide the following additional information:

Amount of death benefit  $ .00
10 yr. 15 yr. 20 yr. 30 yr.

If you would like a Life Insuarance quote on your spouse, please complete the following:
Spouse D.O.B   Gender M F   Smoker Yes No
Amount of death benefit: $ .00
10 yr. 15 yr. 20 yr. 30 yr.

If you would like a Long-Term Care quote for yourself, your spouse or parents, please provide the following additional information:

Yourself      Yes No

Spouse      Yes No

If yes, age of Father Mother
Does anyone to be covered have any significant ongoing medical conditon? Yes No
If yes, please describe:


Does anyone to be covered take any medication? Yes No
If yes, please describe: