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INSURANCE MADE EASY©
COVER YOUR WORLD
Allen/Freeman/McDonnell Agency
will be happy to quote your
Long Term Care Insurance.
Be advised that we are only licensed to provide insurance in Maine. Please answer each question that follows and then send the form to us over the net. We will try to contact you within 24-hours. Thanks for considering
Allen/Freeman/McDonnell Agency.
Information About You
First Name:
Middle Initial or Name:
Last Name:
Address:
City:
State:
Select
Maine
Zip Code:
Phone:
FAX:
E-Mail:
How do you wish to be contacted?
Select
E-Mail
FAX
Phone
LTC Insurance Request
Marital Status:
Select
Single
Married
Divorced
Separated
Widowed
Have Roommate
Life Partner
Do you currently have Long Term Care Insurance?
Yes
No
Long Term Care Insurance Confidential Client Information Worksheet
Client 1
Have you been hospitalized in the last 5 years?
Yes
No
If yes, reason:
Name:
Telephone:
Address:
Date of Birth:
Age:
Height:
Weight:
Smoker:
Yes
No
Medical Conditions:*
Medications & Dosages:*
Have you ever been diagnosed with the following:
heart disease
CHF/CAD
insulin diabetes
emphysema
arthritis
dementia
cancer
osteoporosis
anxiety
depression
stroke or TIA?
Please provide details:
Client 2
Have you been hospitalized in the last 5 years?
Yes
No
If yes, reason:
Name:
Telephone:
Address:
Date of Birth:
Age:
Height:
Weight:
Smoker:
Yes
No
Medical Conditions:
Medications & Dosages:
Have you ever been diagnosed with the following:
heart disease
CHF/CAD
insulin diabetes
emphysema
arthritis
dementia
cancer
osteoporosis
anxiety
depression
stroke or TIA?
Please provide details:
Financial:
Income:
Liquid Assets at Risk
Less than $150,000
$151,000 to $250,000
$251,000 to $500,000
More than $500,000
Social Security $
Pension $
Interest $
Other $
Do you use part of your liquid assets to fund your lifestyle?
select
YES
NO
Medicare Supplement Plan:
A
B
C
D
E
F
G
H
I
J
(Standardized)
(Only Plan C-J Pays Skilled Co-Pay)
Non-Standardized
Prior to 1992?
select
YES
NO
Skilled Co-Pay
select
YES
NO
Are you an Individual Taxpayer?
select
YES
NO
Are you a:
Sole Proprietor
S Corp
LLC
Partnership
C Corp
PA
Please add any additional information or questions in this space.
NOTE:
The sole purpose of this information is to evaluate your risk relative to
Long Term Care Insurance
including insurability as well as suitability. This information is necessary to determine whether or not this type of insurance coverage is appropriate for you. Any offer of insurance will be based on the information you disclose to our representative. It is important to understand that this information will become a permanent part of your file and will not be used for any other purpose. Carroll Harper & Associates assumes no responsibility for misinformation or information withheld. As, always consult your Tax Advisor for professional tax advice.
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Another Search Engine
Business/Yellow Page Directory
Link From Another Site
Thanks for your request! Just click on the SEND button below to send it to us!
NOTICE: Please be advised that insurance coverage cannot be changed or bound by submitting or leaving an electronic message or voice mail message.
Allen/Freeman/McDonnell Agency
or its parent company, Insurance Made Easy, Inc. does not resell or distribute your personal information in any form. We use the information from this form exclusively to try to provide you the insurance coverages which you are requesting. In completing this form, you give us premission to telephone you, if needed.
Last revised:
© 1996-2005 by Insurance Made Easy, Inc.
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