REQUEST A QUOTE - IRA Brokerage

Please indicate the types of insurance

Type of Insurance

Disability Insurance

Life Insurance

Long Term Care Insurance

Agent Information

Client Information

Disability Insurance

Years in Business

Business Type

Number of Employees

Federal/State/City Employee

How Many Years?

Name of Employer

Occupation

Income

(If self-employed, use income after expenses)

Duties

(Include percentage of duties are manual labor, field/lab duties and adminstrative)

Is prospect a business owner?

Yes

No

Percentage of work performed from home:

Premium Payer

Elimination Period

Benefit Period

Benefit Amount

Existing Coverage – Group $

Existing Coverage – Individual $

Additional Comments:

Life Insurance

Will you be replacing?

Yes

No

Inforce Coverage

State

Personal

Business

Benefit Amount

Details for Medical History to include date of diagnosis, treatment, medications and dosage.

Family History: (any occurrence of heart disease or cancer)

Please provide age of diagnosis, age at death or living for Father, Mother and sibling(s).

Relationship

Medical History

Living Age

Age at Diagnosis

Age at death for heart /cancer

Add Remove

Additional Comments:

Long Term Care Insurance

Daily Benefit: $

Show as monthly benefit

Yes

No

Home Care %:

Benefit Period:

Elimination Period:Elimination Period:

Inflation:

HHC Policy Type:

Show limited pay option(s) if available:

Payment Options:

Does your client have problems with memory or other cognitive impairment? If so, please provide details:

Additional Comments:

Additional Information

Date Presenting

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Email

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Please indicate the types of insurance

Agent Information arrowup6

Client Information arrowup6

Disability Insurance

Life Insurance

Family History: (any occurrence of heart disease or cancer)

Long Term Care Insurance

Additional Information

Agent Information

Client Information