February 22, 2012
Tri-City Insurance Service, Inc.

Life/ Health/ Disability/ LTC Quote

Life Insurance Information
Type
Choose the Amount of Death Benefit or Insert Your Own on the right.
For Life Insurance: Permanent or Term Permanent  Term
Insured Information
Insured Name
Address
City
State
Zip
Home Phone
Email
Date of Birth
Gender Male  Female
Use Tobacco Yes  No
Height
Weight
Insured Medical Information
Describe any existing health conditions and/or concerns
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Spouse Insurance Information
Spouse to be Insured? Yes  No
Date of Birth
Gender Male  Female
Spouse Use Tobacco? Yes  No
Height
Weight
Children Yes  No
Spouse Medical Information
Describe any existing health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Children Information
  Date of Birth Gender
Child 1 Male  Female
Child 2 Male  Female
Child 3 Male  Female
Children Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Disability Insurance Information
Occupation
Duties
Salary Earnings
Bonus Earnings
Earnings Frequency Weekly  Monthly  Yearly
Current Disability Coverage? Yes  No
Type of Current Disability Coverage Individual  Group
Current Disability Policy Amount
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD
Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD
Health Insurance
Do you currently have medical coverage? Yes  No
Name of Company Currently Insured With
Type of Coverage Short- Term Medical
Individual/Family Medical
Medicare Supplement
Name & Date of Birth for proposed insureds.
Desired Deductible
Coinsurance
Please add any additional information or requests.
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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