Home Contact Us FAQ Industry Links Site Map

Group Life Group Health Individual Health Hospital Indemnity Short Term Medical Metal Gap Individual Drug Individual Dental Long Term Care Impaired Risk Travel Medical Disability Simplified Life Graded Life For Agents

 

Preliminary Inquiry - Not an application for insurance
 

Applicant Information

P

Applicant's Name (First, Last)

P Address
P City

P

State of Residence

  Zip Code 

P Monthly Income
P Occupation
  Duties

P

Sex

  Male    Female    SS# 

P

Height

     DOB 

P

Weight

     Age 

P

Last Used Tobacco

     Cigarettes   Cigars   Other 

P Hazardous Activity Private Pilot Yes No    Scuba Diving Yes No     Sky Diving     Yes No
 

    Family Health History

P

Father

Age
If deceased, age at death
History of heart disease
or circulatory disorder
History of cancer,
all types

Yes No

Yes No

P

Mother

Yes No Yes No
P

Sister (s)

Yes No Yes No
P

Brother (s)

Yes No Yes No
  Requested plan of insurance - MUST COMPLETE
P Plan Type   Universal Life  Whole Life    Term   Survivorship
P Face amount desired
 

Premium amount desired

Annually
Monthly
P Purpose of insurance
P Beneficiary
P Relationship
 

What adverse reaction or table rating was offered by another company?

P Did your primary company work this case? Yes No       Is this case being considered by another Impaired Risk Agency? Yes No
 
Company Date Amount Action Current Premium Total
 

 
 
 
 

Other insurance on proposed insured

P

Total amount in force

  Date last application   Is this replacement Yes No
P

Current Company

    Premium being replaced   
 

Medical History - This section must be fully completed

P Personal Physician
P Physician Address and Phone Number
P Last consulted     Reason for visit:  
P Other physicians applicant has consulted in past 5 years?
P Clinics, hospitals, sanitariums where applicant has been treated.
P

List current medical conditions of applicant

 
  Other notes regarding this case
 

Agent Information

P Agent Name   
P Agency Name
P Address
P City
P State
P Phone
P Email
P Fax number
  Other Comments

Please be specific with above information and include phone numbers. 
It will expedite processing


Robert D. Fink and Associates  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote.