Broker: Leesa Fons, CLU, ChFC
1700 Eureka Road, Suite 150B
Roseville, CA 95661
Phone: (916) 797-0555
Fax: (916) 797-0515
CA Lic. No.: 0686017
REQUEST FOR INDIVIDUAL DISABILITY INSURANCE QUOTE
Name of Insured:
Phone No: Resident State:
Date of Birth: Gender: Male Female
Tobacco User: None for 2 years or more.
Cigarettes, Pipe or Chew
Cigar only / How often? _________________________
Occupation w/specific duties:
Do you travel for business more than 25%? Yes No
Are you Self-employed? Yes No If Yes, for how long?
If Yes, do you have employees? Yes No If Yes, how many?
Annual Net Income: Last year: 2 years ago:
Are you a Government employee? Yes No If Yes, for how long?
Percent of time you spend in your office?
Do you perform any manual duties? Yes No
Do you supervise employees? Yes No
Do you supervise employees who have manual duties? Yes No
This will be a preliminary quote only. Print this form; fill out and
All final premiums are subject to fax to HealthPoint California
approval from issuing company. at (916) 797-0515.