Delagrange Insurance

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Full Name:
Date of Birth:
Address:
City:
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Phone Number:
Email Address:

Type of Insurance:
Gender:

Amount of Coverage:
Smoker:
Length of Insurance:
Occupation:
Health Condition:
Current Medications:
Additional Information:
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Full Name:

Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Number of Drivers:

Driver 1's Name:
Driver 1's Date of Birth:

Driver 2's Name:
Driver 2's Date of Birth:

Driver 3's Name:
Driver 3's Date of Birth:

Driver 4's Name:
Driver 4's Date of Birth:

Driver 5's Name:
Driver 5's Date of Birth:

Driver 6's Name:
Driver 6's Date of Birth:

Number of Vehicles:

Vehicle 1's Vin #:

Type of Coverage:

Bodily Injury:

Property Damage:

Additional Information:

How did you hear about us?

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Full Name:

Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

How many in your family?

How many will apply for health insurance?

Name of Applicant #1:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #2:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #3:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #4:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #5:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #6:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #7:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #8:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #9:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Name of Applicant #10:

Date of Birth:

Occupation (Adults only):

Employer (Adults only):

Currently on Group Insurance?

Any health problems?

Any prior surgeries?

Taking any medications?

Did you recently lose health insurance coverage?

Additional Information:

How did you hear about us?

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Full Name:
Date of Birth:
Address:
City:
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Phone Number:
Email Address:

Doctors:
Currently on Medicare?
Currently on a plan with our office?
Which plan?
Current Insurance Plan:

How did you hear about us?
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Full Name:
Date of Birth:
Address:
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Do you currently have other long term care coverage?
Please explain:
Health Condition:
Smoker:
Current Medications:
Please explain:
Do you currently need assistance for bathing, dressing, eating, moving in/out of bed or chairs, toileting, bowel or bladder control?
Do you use a walker, wheelchair, oxygen, dialysis, respirator, quad cane or motorized cart?
Within the past 10 years, have you been diagonosed or treated for: alzheimer's, chronic memory loss, senility, dementia, Lou Gehrig's Disease, MS, parkinso's muscular distrophy, cerebral palsy or spina bifida?
Within the past 10 years have you been diagnosed or treated for: multiple episodes of strokes or transient ischemic attacks, cirrhosis of the liver, systemic lupus or polycystic kidney disease, AIDS, HIV or AIDS related complex?
Have you had a heart, back or spine surgery within the past 6 months?
Have you had a heart attack wthin the past 12 months?
Have you had a transient ischemic attack, a stroke or mini stroke within the past 12 months?

How did you hear about us?
Please explain:

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Group Name:
Phone Number:
Contact Person:
Email:
Number of Employees:
Location
City:
Zip Code:
State:

How did you hear about us?
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Full Name:
Date of Birth:
Address:
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Zip Code:
Phone Number:
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Occupation:
Tobacco Use:
Salary or Net Income:
Who is paying the premium?
Are you:
Length of Time Owned:
Number of Employees:
Health Condition:
Monthly Benefit:
Please Enter Your Dollar Amount:
Elimination Period:
Benefit Period:
Optional Benefits:	Residual Social Security Rider COLA Future Purchase Select All
How did you hear about us?
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Full Name:
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Surrender Period:
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Tax Qualified:
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Full Name:
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Address:
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Ownership:
Joint - Name:
Joint - Date of Birth:
Joint - Sex:
Tax Qualified:
Amount of Investment:
Income Options:	Life only Life with 5 year Certain Life with 10 year Certain Life with 15 year Certain Life with 20 year Certain Life with 25 year Certain Life with 30 year Certain Life with Cash Refund Life with 25% Death Benefit Life with 50% Death Benefit All Of the Above Unsure
Payment Frequency:
Optional Rider:	Changing Needs Option Inflation Protection Unsure
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