Melissa Shaw, Planner

I'll send you a quote

For a fast insurance quote, fill out this online form and click the Send Form button. Or, you may click here to download a one-page PDF version that you can print, fill out and fax to me.

Tips: Pressing your TAB key will move you from field to field. Pressing your SPACEBAR will toggle checkboxes on and off. Broker Name*, Broker Phone* and Broker Email* are required fields.

Personal Insurance Proposal Request

Client Name:

Height:   Weight:   Date of Birth:

Age Last:   Age Nearest:

Smoker   Non-Smoker

 

Spouse Name:

Height:   Weight:   Date of Birth:

Age Last:   Age Nearest:

Smoker   Non-Smoker

Life Insurance

Face Amount $

$250,000    $500,000    $1,000,000

Term Insurance:

Product: 10 year  15 year   20 year

Permanent Insurance

Premium $

Add’l Pour In $ Year 1:

Ten Pay Death Benefit:
Pay to Age 65 Option A-Level
Income @ Age: Option B-Increasing

Long Term Care, Plan Design

Daily Benefit: $80   $100   $120   $140   $150     Other $

Benefit Period: 1yr 2yr 3yr 4yr 5yr Unlimited

Waiting Period in days: 0 30 60 90 100 180

Home Health Care Waiting Period: 10 days or Match Nursing Home Waiting Period

5% Compounded   5% Simple

Coverage in the California Partnership? Yes   No

Annual Income if available: $

Guestimate of Net Worth if available: $

Health History or Comments:


 

Broker: * Phone: *
Email: * Need by (date):

*Broker Name, Broker Phone and Broker Email are required fields.