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General Information, Individual & Senior Plans Inquiry Form

Name : 
Address :
City, State Zip :  ,
Daytime Phone : 
Evening Phone : 
Fax Number : 
Cell Phone / Pager : 
Email Address : 
Date of Birth: 
Gender :  Male     Female
Marital Status :  Single     Married  (if married, enter your spouse's date of birth)
                           
 
Coverage : 

Myself     Myself & Spouse     Family
Myself & Child       Myself & Children
Children Only   (if children only, how many children)

 
Current Carrier : 
Currently on Cobra?  Yes     No
Existing Medical Conditions: 
Current Medications : 

I would like to know more about :
 HMO   PPO   POS   Hospital Only
  Medicare Supps   Medicare HMO   Dental

For Life Insurance:
If this applies to you, please fill out all fields.
Smoker:  Yes     No
Amount of Insurance: 
Type:  Term     Whole      Universal      Variable Universal

For Disability:
If this applies to you, please fill out all fields.
Smoker:  Yes     No
Gross Income : 
Per: 
Occupation: 
Education Background : 
Employer: 
How long with employer: 
How long in occupation: 
Duties: 
Describe in detail
If self-employed,
How long: 
If doctor, specialty : 
Benefit period :  1 yr     2 yr     5 yr     To age 65
Elimination period :  30 days     60 days     90 days     180 days
   
Additional Comments:
   

   
  
 
Last Updated: November 2008
Jay Baldauf
Lic. No. OA96152
12312 Pentagon Street   •   Garden Grove, CA 92841-3327
Tel: 714.638.0853   •   800.731.2590   
Email: jay@archapple.com