Name     Title

Company

Address

City   State AK AL CO FL GA IL IN KS KY LA MD MI MO NC NE NV OH OK PA SC TN TX VA WV      Zip Code + 4 

E-mail Address

Phone   Best Time To Call FAX

BASIC PERSONAL INFORMATION (Required for ALL Quotes)

Sex Male Female        Tobacco User? Never Used Tobacco Former User - Quit > 1 Year Ago Pipe/Cigar Smoker Smoked, but never inhaled         HT   WT

Birthdate (MM/DD/YY)     Occupation

Tell us the medical history for everyone to be insured - Please Be Specific w/Person/Dates/Diagnosis/Treatment, etc.

I am interested in reviewing quotes for the following coverage(s):

           MEDICAL INSURANCE   

 Type of Plan     Not Interested In Medical Insurance At This Time Medical Insurance - Cover Florida Plan Medical Insurance - HMO Medical Insurance - PPO Medical Insurance - Indemnity Plan Medical Savings Account - High Deductible/Tax Advantaged Plans Medical Insurance - HIPAA Guaranteed Issue Coverage Medicare Supplement - Age 65 Medicare Supplement - Disability Medical Insurance - Short-Term Coverage Cancer/Dread Disease Insurance Hospital/Surgical Coverage Only Medical Insurance - International Travelers

 Spouse to be Insured? No    Yes        Spouse Birthdate (MM/DD/YY)  

HT   WT     Is Spouse a Tobacco User? Never Used Tobacco Former User - Quit > 1 Year Ago Pipe/Cigar Smoker Smoked, but never inhaled   

  Child(ren) to be Insured? No    Yes        Sexes/Ages Female < 5 yrs old Female 5 - 10 years old Female 11 - 18 years old Female 18 - 25 years old Male < 5 years old Male 5 - 10 years old Male 11 - 18 years old Male 18 - 25 years old

            LIFE INSURANCE

  Type of Plan Not Interested In Life Insurance At This Time Term Life - 10 Yr Guaranteed Level Premiums Term Life - 15 Yr Guaranteed Level Premiums Term Life - 20 Yr Guaranteed Level Premiums Term Life - 30 Yr Guaranteed Level Premiums Term Life - Annual Renewable Term Variable Universal Life Universal Life - Fixed Interest Rates Survivorship (2nd to Die) Life Guaranteed Issue/Modified Benefit Plan     Coverage Amount $10,000 - $25,000 $25,001 - $50,000 $50,001 - $100,000 $100,001 - $150,000 $150,001 - $250,000 $250,001 - $500,000 $500,001 - $750,000 $750,001 - $1,000,000 $1,000,001+

   Reason for Coverage Family Protection Collateral for Loan - Individual Collateral for Loan - Business Non-qualified Deferred Compensation Business Buy-Sell Funding Estate Tax Funding Corporate Split Dollar Plan Key Employee Policy      Are you a pilot? NO Yes - Fly Regularly Yes - Fly only occassionally Yes, but I'm a lousey pilot

    Are you replacing a current policy? No    Yes            Cash Value of current policy None < $2,500 $2,501 - $10,000 $10,001 - $25,000 $25,001+

           LONG TERM CARE  (NURSING HOME) INSURANCE

    Type of Plan Not Interested In Long-Term Care At Present Comprehensive Nursing Home Home Health Care Only Assisted Living Facility and Home Health Care     Daily Benefit Amount $50 per Day $60 per Day $70 per day $80 per Day $90 per Day $100 per day $125 per Day $150 per Day $175 per Day $200 per Day $225 per Day $250 per Day $275 per Day $300 per Day

    Waiting Period 0 Day 30 Day 60 Day 90 Day 180 Day     Benefit Period 2 Year 3 Year 4 Year 5 Year 6 Year Lifetime     Inflation Adjustment None Simple Interest Each Year Compound Interest Each Year

    Spouse to be Insured? No    Yes        Spouse Birthdate (MM/DD/YY)  

            DISABILITY INCOME INSURANCE 

Please call us for information on rates and availability of individual disability income insurance.  Because of the complexity of variables which go into the rating of these contracts, recent changes in many contractual provisions, the increased Underwriting scrutiny and the limited number of carriers still in this market, it is impossible for us to adequately provide you realistic quotes via our website.