Life Insurance

Contact me regarding the following type(s) of life insurance:

Term Life: 5-Year 10-Year 15-Year 20-Year 25-Year 30-Year
Universal Life Variable Universal Life
Whole Life Guaranteed Issue Life Survivorship Life

Amount of Insurance

Date of Birth Male Female Tobacco User Non-Tobacco

Contact me regarding disability insurance.

I have group disability insurance through an employer or association.
Yes No Don't Know

If yes, indicate the type of group disability insurance (check all that apply):
State Mandated Short-Term Disability
Group Short-Term Disability - dollar amount per month or percentage
Group Long-Term Disability - dollar amount per month or percentage

I have an individual disability insurance policy.
Yes - dollar amount per month
No

Yearly Income $ 20,000 - $ 29,999 $ 30,000 - $ 39,999 $ 40,000 - $ 49,999 $ 50,000 - $ 59,999 $ 60,000 - $ 69,999 $ 70,000 - $ 79,999 $ 80,000 - $ 89,999 $ 90,000 - $ 99,999 $100,000 - $199,999 $200,000 - $299,999 $300,000 - $399,999 $400,000 - $499,999 $500,000 and over

Occupation

Describe Job Duties


Date of Birth Male Female Tobacco User Non-Tobacco

Contact me regarding long-term care insurance.

I am a member of a group or association that has a discount program.
Yes No Group is Interested

If yes or interested, provide Group / Association / Employer Name:

I am interested in the New York State Partnership for Long-Term Care Program.
Yes No Not Sure

Date of Birth Male Female

Also provide information for my spouse.

Spouse's Name

Date of Birth Male Female