| Please print, then fill out and FAX this short
questionnaire to (860) 295-6433 so we can serve you as quickly
as possible. |
What are your insurance
needs today?- Individual or Family Health Insurance
- Life Insurance
- Disability Insurance
- Medicare Supplemental Insurance
|
| Name: |
| Age: Height: Weight: Sex: |
| How many dependents? |
| Spouse: |
| Age: Height: Weight: Sex: |
| Phone #: |
| Email Address: |
| Home Address: |
| City: |
| State: Zip: |
Are you currently taking any medications?
|
| Do you
have any pending surgeries?
|
Had any health problems (such as cancer, diabetes or heart
problems) within the past 5 yrs?
|
Is anyone
to be considered for coverage currently pregnant?
|
| Comments:
|
| What is the best time to call you? |