Posts Tagged ‘information sheet’

Medicare Healthcare Plans Quote

Wednesday, May 26th, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Part I – Applicant Information

Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Spouse Information
Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Applicant Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Email Address
Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.
A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?
If yes, please describe
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?
If yes, please describe
B. Do you have any other health insurance coverage that provides Medicare benefits?
If so, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program:
1. As a Specified Low-Income Medicare Beneficiary (SLMB)
2. As a Qualified Medicare Beneficiary (QMB)
3. For other Medicaid medical benefits?
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insured)
Within the past two (2) years have you had, or had a medical diagnosis of:
a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?
e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?
2. Are you an insulin dependent diabetic taking more than 50 units per day?
3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?
4. Are you currently hospitalized, or receiving Medicare approved home health care; or have you been hospitalized or received Medicare approved home health care three or more times in the past two years?
5. Within the past year have you been medically advised to have surgery but not had such surgery?

Long-Term Care Quote

Friday, May 21st, 2010

Please complete the following information, if you would like to obtain a quote .  This is not an application. If you would like to have coverage, an application will be sent to you.

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

Personal Information

Name
Email Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Birth Date
Gender
Height (example 5'8")
Weight (lbs.)
Are you married?
If so, Spouse's Birth Date
Fill in spouse if spouse is also applying
Do you smoke?
Spouse smoke?
Are you diabetic?
Spouse diabetic?
Are you insulin dependent?
Spouse insulin dependent?
Do you use a cane?
Spouse use a cane?
Do you use a walker?
Spouse use a walker?
Do you use a wheelchair?
Spouse use a wheelchair?
Do you use any other equipment?
Spouse use any other equipment?
Please explain if you have required assistance with everyday activities in the past 2 years:
Please explain if your spouse has required assistance with everyday activities in the past 2 years:
In the past 5 years have you: (check all that apply)
Please describe your particular health problems:
In the past 5 years has your spouse: (check all that apply)
Please descirbe your spouse's particular health problems:
Prescribed Medications:
Spouse's Prescribed Medications:
Do you currently own a long-term care policy?
Does your spouse currently own a long-term care policy?
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:
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Variable Life Quote

Friday, May 21st, 2010

If you would like to obtain a quote, please complete the following information.  Please understand, this is not an application.   If coverage is desired, an application will be sent to you.

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

Personal Information

Universal Life Quote

Friday, May 21st, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Street Address
City and Zip
Telephone
Alternate Telephone
Fax Number
Email Address
Quote Information
What Benefit Amount do you want?
What is your purpose for buying Life Insurance Protection?
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
Have parents or siblings been treated for cancer, diabetes, or cardiovascular disorders prior to Age 60?
If yes, please describe
What medications 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?
Do you plan to replace your current policy(ies)
Do you want to add any endorsements (such as child rider)
Comments or Questions
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Term Life Quote

Friday, May 21st, 2010

If you would like to obatin a quote, please complete the following information. Please understand, this is not an application. If coverage is desired, an application will be sent to you.

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

Personal Information

Group Health Insurance Quote

Friday, May 21st, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Company Name
Street Address
City and Zip
What is your position?
Email Address
Phone Number
Alternate Telephone
Fax Number
Best time to call?
Does your company currently have health insurance
If so, name of current carrier
Anniversary Date of current plan
Total Number of Employees (including officers/owners)
Number of Employees to be Insured
Are premiums paid by your company for employee only or spouse too?
Current rate for coverage is:
Please list the company you would not like quoted:
What type of plan do you want compared?
Please choose from the following deductibles:
Would you like a Prescription Plan?
Please select from the following co-insurances:
What do you like or dislike about your current plan?
Additional remarks or requests
Census
Company Name
City
Zip Code
Employee Data
Employee 1
Birth Date
Gender
Zip Code
Select Coverage
Employee 2
Birth Date
Gender
Zip Code
Select Coverage
Employee 3
Birth Date
Gender
Zip Code
Select Coverage
Employee 5
Birth Date
Gender
Zip Code
Select Coverage
Employee 6
Birth Date
Gender
Zip Code
Select Coverage
Employee 7
Birth Date
Gender
Zip Code
Select Coverage
Employee 8
Birth Date
Gender
Zip Code
Select Coverage
Employee 9
Birth Date
Gender
Zip Code
Select Coverage
Employee 10
Birth Date
Gender
Zip Code
Select Coverage
If more employees are to be covered, please send census data by email to info@HatcherKimrey.com

Individual Health Insurance Quote

Friday, May 21st, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Street Address
City and Zip
County
Phone Number
Alternate Telephone
Email Address
Applicant / Family Member to be enrolled
Is this applicant currently insured with major medical or has been within the last 30 days
Applicant Gender
Applicant height (example 5'8")
Applicant Weight (lbs.)
Applicant Birth Date
Applicant Tobacco Use
Spouse Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Spouse Height (example 5'8")
Spouse Weight (lbs.)
Spouse Birth Date
Spouse Tobacco Use
Child 1 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 1 Height
Child 1 Weight
Child 1 Birth Date
Child 2 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 2 Height
Child 2 Weight
Child 2 Birth Date
Child 3 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 3 Height
Child 3 Weight
Child 3 Birth Date
Child 4 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 4 Height
Child 4 Weight
Child 4 Birth Date
Explain any health problem that could affect premium:
Any special requests or remarks?
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Homeowners Flood Quote

Thursday, May 20th, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Business Name
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Email Address
Building & Property Information
Property Street Address
City
State
Zip Code
Occupancy Type
Building Type
Year Built
Flood Map Zone Number
Community Flood Number
Number of Bedrooms
Number of Bathrooms
Number of Fireplaces
What date was the property purchased?
Does the residence have a basement?
Total Square Footage of Building
How many units are in the building?
Garage Description
How many stories is it?
What is the construction type?
What is the foundation type?
What is the nature of sub-soil?
What is the topography?
What type of roof covering?
Is the roof updated?
If yes, what year?
Is there any erosion in the area?
Is there any below ground parking?
Is there any soft first story or tuck under parking?
What is the distance to fire protection?
Is the business in a brush area?
If yes, has the brush been cleared by 250 feet from all around the building?
Are there smoke detectors at this location?
Are there fire extinguishers?
Are there circuit breakers?
Is the electrical updated?
How old is the heating/ air conditioning?
What is the energy source?
Has the plumbing been updated?
If yes, what year was the plumbing updated?
Is the plumbing copper?
Does the building have interior automatic fire sprinklers?
Is there a fire alarm?
Has the building been retrofitted or bolted?
Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the building coverage requested?
What is the other structures coverage requested?
What is the contents property coverage requested?
What is the loss of use coverage requested?
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Mobile Home Quote

Thursday, May 20th, 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 on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Email Address
Age of oldest owner
Property Information
Property Street Address
City
State
Zip Code
Purpose of Use
If commercial, how is it used?
What is the mobilehome park's name? (if on private property, please indicate)
What is the number of spaces in the park?
What year was it built?
What is the serial number?
What is the mobilehome manufacturer name?
What is the current loan amount?
Is the mobilehome tied down?
Is the mobilehome fully skirted?
Is it located within city limits?
Does the mobilehome park have a full-time resident manager?
Is it located on private property?(not in a park)
Have you ever been refused insurance in the last 3 years?
Is it located in a landslide Area?
How many stories?
If two stories, what is the ground floor square footage?
What is the total square footage of the dwelling?
Length and width of mobilehome
What is the construction type?
If structure is located in a flood zone, what is the distance to body of water?
What type of roof covering?
Was the roof updated?
If yes, what year?
What is the distance to fire protection?
Is the building in the brush?
Is there a brush hazard within one mile of the building?
If yes, has the brush been cleared by 250 feet from all sides of the building?
Is there a smoke alarm?
Is there a fire extinguisher?
Are there deadbolts?
Is the electrical updated?
Are there circuit breakers?
Does the electrical circuit box have copper wiring?
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?
What is the energy source?
What is the heating system?
What is the cooling system?
Has the plumbing been updated?
Is the plumbing copper?
Does the mobilehome have a woodstove?
Does the mobilehome have a fireplace?
Does it have interior automatic fire sprinklers?
Is there a theft alarm?
Is there a fire alarm?
What is the earthquake zone?
Has it been earthquake retroffited?
Are there dogs on the property?
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Business Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
Policy Deductible
If earthquake insurance is requested, select deductible percentage %
Do you want building replacement cost coverage?
Do you want contents replacement cost coverage?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

Homeowners Quote

Thursday, May 20th, 2010

If you would like to obtain a quote on Homeowners Insurance. please complete the following information .  This is not an application for insurance.   If coverage is desired, an application will be sent to you.   All information provided is confidential and will be used solely for the purpose of providing a quote for you.  Most companies require credit scoring to quote their best rates.   By providing the information contained in this form, you authorize us to obtain a credit score on your behalf.  Please know this is a soft hit to your credit and does not effect your credit score.

The home may be a single family owner occupied dwelling (home), condo or townhome. This program may provide dwelling fire coverage, contents – personal property, loss of use, seperate structures such as a detached garage or shed, premise medical and premise liability insurance.

Complete this form to get a quote on a single family owner occupied home, condo or townhouse.

Name
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Social Security Number
Birth Date
Email Address
Property Information
Property Street Address
City
State
Zip Code
Dwelling Type
Number of Bathrooms
Number of Fireplaces
What year was it built?
What is the construction type?
How many stories is it?
Total square footage
What foundation type?
Garage Description
Number of Cars
What type of roof covering?
Was the roof updated?
If yes, what year?
Does the building have a pool?
If yes, what type of pool?
If yes, is it fenced?
If there is a pool, is there a diving board?
If there is a pool, is there a slide?
Is there a smoke alarm?
Is there a fire extinguisher?
Are there deadbolts?
Is the electrical updated?
Are there circuit breakers?
How old is the heating/ air conditioning?
What is the heating system?
What is the cooling system?
Has the plumbing been updated?
Is the plumbing copper?
Is there a theft alarm?
If monitored, by whom?
Are there dogs on the property?
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Premise Liability - Coverage E
Policy Deductible - Wind/Hail
Policy Deductible - All Other Perils
Do you want building replacement cost coverage?
Do you want contents replacement cost coverage?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other: