Archive for the ‘Products’ Category

Health Links

Thursday, June 24th, 2010

Health Insurance Links

WebMD.com
Everything you need to know about your health.

American Association of Health Plans
The American Association of Health Plans is the national trade association representing more than 1,000 health maintenance organizations, preferred provider organizations, point-of-service plans, and other similar health plans that care for more than 140 million Americans.

Permanent Life Quote Request

Tuesday, June 15th, 2010

Complete the following information if you would like to obtain a quote.  Please understand this is not an application.  An application will be sent to you if coverage is desired.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.


Last Name
First Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Email Address
Fax Number
What Benefit Amount do you want?
What is your purpose for buying Life Insurance?
Birth Date
Gender
Height (example 5'8")
Weight (lbs.)
Tobacco Use
Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
If yes, please describe
What medication are you taking? Please give dosage and frequency
Explain any health problems that you think would impact the rate:
Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
If yes, please describe
What is the amount of Current Life Insurance?
What are your current Life Insurance Companies?
What is your current monthly life premium?
Are you wanting to replace your current policy(ies)
Do you want to add any endorsements (such as child rider)
Comments or Questions
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Home Claim

Thursday, May 27th, 2010

Please take a few moments and complete the following information.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing your request.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Property Address
Street Address
City
State
Zip Code
Loss General
Date of Loss
Time of Loss Discovery
Cause of Damage
Police or Fire Department Called:
If yes, which one?
Property Inhabitable:
Short Description
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Auto Claim

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will not be used for any purpose other than its intended use.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Vehicle Involved
Make
Model
Year
Loss General
Date of Loss
Cause of Damage:
Estimated Damage
The following section is applicable to Accident only
Driver First Name
Driver Last Name
Relationship to Applicant:
Time of Accident
Number of Cars Involved:
Police Notified:
Estimated Percentage at Fault:
Location of the Accident
Street / Highway
City / Town
State
Short Description
Other Party Information (if available)
Other Driver Name
Address
Home Phone
Work Phone
Driver's License
License Plate
License State
Insurance Company
Policy Number
Vehicle Year/Make/Model
Damage Description
The following section is applicable to Theft only
Time Loss Discovered
Date Police Notified
Vehicle Recovered
Date Vehicle Recovered
Short Description
Online Claim Notice

Change of Address

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Change Address Information
Old Address:
New Address:
City and Zip
Phone
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Delete Driver

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Driver
First Name
Last Name
Relationship to Applicant:
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Add Driver

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Policy Number
Name of Insurance Company on Policy:
Driver Information
Name
Birth Date
Relationship to Applicant:
Gender
License #
Years Licensed:
If youthful driver, have you completed a state-approved drivers education course approved by the state
Marital Status
Job Description
Which Vehicle does the person drive?
DUI or DWI in last 6 years?
Has your license been suspended in the last 5 years?
Has your license been revoked in the last 5 years?
Do you require a SR-22?
Number of Violations in the last 5 years:
Number of Accidents in the last 5 years:
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Delete Vehicle

Wednesday, May 26th, 2010

Please take a few moments and complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Vehicle
Year
Make
Model
Vin #
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Change Vehicle

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Existing Vehicle
Year
Make
Model
Vin #
Add New Vehicle
Year
Make
Model
Vin #
Estimated Annual Mileage
Vehicle Use
Miles to Work/School (1 way)
Ownership
Purchased / Leased On
Purchase Price
Primary Driver
Lienholder Name (if leased or financed)
Additional Insured
Coverages Section
Comprehensive Deductible
Collision Deductible
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Change Vehicle

Wednesday, May 26th, 2010

Please complete the following information.

All information provided on this information sheet is confidential and will be used solely for the purpose of processing your request.

Contact Information