Boca Raton & West Palm Beach, Florida Insurance - Reliable Insurance & Financial Services

FREE QUOTES (Personal - Health, Life, Dental and/or Disability)

No agent will call on you unless you request that we call you. All quotes request information submitted to our agency will be kept in strict confidence. We wil not distribute this information to anyone or any organization other than insurance companies for quotes. We shop the marketplace for you and provide you with the three most competitive plans and prices we find on your behalf. Quotes are e-mailed within 24 hours.

I am interested in the following:	Health
	Dental
	Life
	Disability Income Protection

Your Name:

E-Mail Address:

Date of Birth:

Sex:	Male
	Female

Have you smoked tobacco products within the last 12 months?:	Yes
	No

Spouse coverage desired?	Yes
	No

Spouse Date of Birth:

Have your spouse smoked tobacco products within the last 12 months?:	Yes
	No

# of Children to be covered:

Ages of Children:

City or County of residence:

Phone number:

Do Children reside with you?	Yes
	No

If no, what city, state:

Are you self-employed?	Yes
	No

If yes, name of company:

Please mark insurance coverages you now have:	Health
	Dental
	Life
	Disability

Reason for shopping for coverage (ie., looking for better coverage, less expensive coverage, curious, etc.:

HEALTH HISTORY

Do you or any family members to be covered have any of the following medical conditions? (please check all that apply)

Diabetes
Pregnant
Heart Conditions
Hypertension
Back Disorders
High Cholesterol

Cancer
Drug Abuse
HIV/AIDS
Arthritis
Obesity
Liver/Thyroid Disorders

Disabilities
Mental Disorders
Neurological Disorders
Allergies/Asthma
Urinary Disorders
Female Disorders

Please provide details to any medical condition listed:

Are you or any covered family members taking medication? If so, please specify:

Additional information: If you are shopping for health insurance, please let us know if have preferences such as doctors, hospitals -- HMO plans, PPO plans, POS plans, high deductible plans, lowest rates, etc:

If shopping for Life Insurance, provide us with the following information:

Profession:

Preference on types of insurance desired:	Term
	Universal Life
	Whole Life

Death benefit amount desired (you may indicated more than one):

Reason for life insurance:	Debt protection (mortgage, car, etc)
	Childrens' education
	Retirement security
	Family security
	Business Continuation Insurance
	Estate preservation
	Other:

Have you or anyone in your family to be covered been denied or rated by an insurance company in the past 5 years?	Yes
	No

If yes, please specify reason for denial or rating:

Questions or Comments:

For Disability Income, we will need information about your income to provide quotes as all plans are based on protecting your income.

Previous 12 months annual income or average monthly income:

Current monthly income:

Do you work from your home?	Yes
	No

Are you self-employed?	Yes
	No

Number of years/months at current profession:

Number of hours per week at profession:

Job description: (please list duties and provide details):

Have you been disabled and/or collected disability in the past?	Yes
	No

If yes, please provide details of disability:

Do you currently have disability income protection coverage?	Yes
	No

Reason for shopping for coverage:


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How to Contact Us
Reliable Insurance & Financial Services
1685 N. Florida Mango Road, Suite E
West Palm Beach, FL 33409

Phone: (561) 687-1130
(800) 663-8070
Fax: (561) 688-0955
E-mail: LTCExpert1@aol.com