Insurance Services

INSURANCE SCREENING FORM

In order for us to offer you the most comprehensive coverage at the lowest rate available, please answer the following questions as completely and accurately as possible. Thank you.

  PERSONAL INFORMATION    
     
  Name  
  Title  
  Address  
  City  
  State  
  Zip  
  Phone  
  Email  
  What type of insurance do you need?    
               *Life   Yes  No
               *Health   Yes  No
               *Disability   Yes  No
               *Long Term Care   Yes  No
               *Medicare Supplements   Yes  No
               *Dental   Yes  No
  Who are we insuring?  
  How long in practice?  
  DOB  
  Gender    Male  Female
  Smoker?    Yes   No
  If quit...how long since you quit?  
  Use any nicotine substitute  
       
  HEALTH INFORMATION    
       
  Have any health problems?    Yes   No
  What kind?  
  Do you take medication of any kind?   Yes   No
  If yes, specific name and dosage  
  How long have you been taking it?  
  For what? (specific diagnosis if they know it)  
  (If for high blood pressure) is blood pressure controlled on the medication?  
  Have you had any recent surgery?  
       
  BUSINESS INFORMATION    
       
  Gross Income   (over 12-month period)
  Net Income  
  Business entity...    sole proprietorship   corporation
     (& what type?)  
  How Long?  
  OTHER INTERESTS    
       
  Do you have any long-term care insurance?   Yes   No
  Who is it with?  
  What is the premium?  
  Do you have any life insurance?   Yes   No
  Who is it with?  
  What is the premium?  
  What kind?   -term   -whole   -variable
  How long have you had it?  
       

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This page was last updated on: 12/13/04 11:47 AM