| Association Information |
| Do you currently belong to an association? |
Yes
No
|
|
Name of Association
|
Membership #
|
|
|
Which association are you interested in joining?
|
How did you hear about us?
|
|
| Contact Information |
First Name
|
Last Name
|
Business Name
|
|
E-Mail
|
Address (line 1)
|
Address (line 2)
|
City
|
State
|
Zip code
|
Main Phone
|
Mobile Phone
|
Best phone to call
|
Best day to call
|
Best time to call
|
|
| Personal Details |
Gender
|
Marital Status?
|
Date of birth
|
Occupation
| Height
ft.
in. |
Weight
lbs |
| |
Do you use tobacco?
Yes
No |
| Spouse Details |
| Do you have a spouse? |
Yes
No
|
| Might you have a spouse in the future? |
Yes
No
|
First Name
|
Last Name
|
Date of birth
|
Occupation
|
Height
ft.
in. |
Weight
lbs |
Does he/she use tobacco?
Yes
No |
| Children |
| Number of children to be insured
|
First Name
|
Last Name
|
Gender
|
Date of birth
|
| Is anyone expecting a baby? |
Yes
No |
First Name
|
Due Date
|
| Medical History |
| Does anyone take medications on a regular basis? |
Yes
No |
First Name
|
Medication
|
Condition
|
Dosage
|
| Add more... |
| Has anyone been prescribed medication, but is not taking it? |
Yes
No |
Why not?
|
| Has anyone received long term care in the past 3 years? |
Yes
No |
In the past 10 years has anyone had any symptoms, diagnosis, consultation or treatment for any medical condition (other than colds, flus, routine exams, etc.)?
Yes
No
|
First Name
|
Diagnosis
|
Treatment
|
| Add more... |
Has anyone been declined for long-term care in the last 5 years?
Yes
No
|
First Name
|
Why?
|
Through which carrier?
|
| Add more... |
I have reviewed this section and have noted all medical issues honestly and to the best of my knowledge.
|
| Additional Information |
| When do you want/need your insurance to start? |
Not Urgent
ASAP
Specific Date
|
| Do you want to receive care locally? |
Yes
No |
If not, which area/city do you want to receive care?
|
How would you prefer to pay your premiums?
Pay more in early years, less in later years
Pay less in early years, more in later years
Pay it off in one large premium
|
Do you want to have LTCI/protection for...
|
| Please enter any additional information or comments below. |
|
| I'm also interested in: |
Accident Insurance
Business Insurance
Critical Illness
Dental/Vision Insurance
Disability Income
|
Health Insurance
Life Insurance
Medicare for Seniors
None at this time
|
| Thank you for completing the form, so we can better assist you. We look forward to working with you! Please press submit now and we will contact you within 2-3 business days. |
|
