REQUEST FOR INDIVIDUAL DISABILITY INSURANCE QUOTE

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					                                                       Broker: Leesa Fons, CLU, ChFC
                                                       1700 Eureka Road, Suite 150B
                                                       Roseville, CA 95661
                                                       Phone: (916) 797-0555
                                                       Fax: (916) 797-0515
                                                       Email: Leesa@HealthPointCalifornia.com
                                                       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.

				
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