Please complete sections I, II and III to receive a quote on the insurance coverage(s) you are seeking. To submit your request by fax or mail, please download the pdf form HERE (Adobe Reader v7.x required) and follow the instructions on the form.
Section I. Contact Information for the person requesting a quote (all fields required)
Name:
E-mail:
Street Address: City:    
Zip Code:
Telephone number: (please include your area code)
Best time to call:


Section II. Who is the person being insured? (all fields required)
Myself      My Spouse      My Parent(s)      My Child(ren)      Other:
Name:
Date of Birth:     Does this person smoke?
Street Address: City:    
Zip Code:

Section III. Insurance Products (select and complete each product of interest)
A. Disability Insurance (if this box is checked, please provide information listed below)
Annual Income:
  (maximum benefit is based on previous year's income)
Job Title:
   Position:
Waiting Period:
(how long before an approved claim benefit starts)
30 days     60 days        90 days     no waiting period
      Length of Employment (in years): Monthly Benefit Requested:


B. Health Insurance (if this box is checked, please provide information listed below)
Type:
     Individual HMO  Individual PPO
     Group HMO       Group PPO      Group offering both
       Company Preference(s):
Blue Cross   Blue Shield    CIGNA Kaiser
PacifiCare   Other (please specify):


C. Life Insurance (if this box is checked, please provide information listed below)
Term (select number of years below)
5 years      10 years      15 years      20 years      30 years
Whole Life/Permanent to Age 100+
Amount of Coverage Requested: $
AND/OR
Please indicate the amount of coverage that can be purchased for $ per month

Does the proposed insured have any of the following conditions? (please check all that apply)
High Blood Pressure Heart Disease
Diabetes

Cancer
If in remission, for how many years: 


D. Long-Term Care (if this box is checked, please provide information listed below)
Benefit Period
(how long a benefit is paid per claim):
3 years      6 years      Lifetime
Waiting Period:
(how long before an approved claim benefit starts)
30 days     60 days        90 days     no waiting period
Daily
Benefit Requested:
$150       $200       $250       Maximum
Other, please indicate amount:
Does the proposed insured have any of the following conditions? (please check all that apply)
Cancer Heart Disease
Diabetes Confined to Hospital/Nursing Home
Insulin-Dependent Had Home Care
Use Cane Had Long-Term Care
Use Walker Received Rehabilitation
Use Wheelchair





To receive a quote for another individual, please complete a separate form.
Insurance Quote Form
CA License #ØD6Ø143 & ØD8Ø856