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AEP
Licensing & Contracting
Contracting Tools
Find Out More (FAQs)
Products & Carriers
Carrier Selection
Forms & Supplies
Incentives & Trips
Quoting & Technology
Medicare Center
Quoting Tools
Underwriting
Marketing & Leads
Brochures
Consumer Presentations
Email & Postcards
Leads & Prospecting
Logo Design
Marketing Program
Product Fact Sheets
Social Media
Websites
>
Consumer Website Quoting Tool
Tools & Training
Education & Training
Referral Program
Secure File Upload
Tips of the Trade
Webinars
About & Contact
Contact
Meet the Team
News
Our Story
Testimonials
The Resource Blog
Client Information
*
Indicates required field
Name of Insured
*
First
Last
Date of Birth
*
Gender
*
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Height
*
Enter as 5'7" format.
Weight
*
State
*
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Tobacco Use
*
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No
If yes, date last used.
*
Type of Tobacco Used
*
Cigarettes
Cigars
Pipe
e-Cigarettes
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Hookah
Kreteks
Occupation/Industry
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Responsibilities/Duties
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Annual Income
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U.S. Resident?
*
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U.S. Citizen?
*
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Resident Country (if not U.S.)
*
Coverage Details
Monthly Benefit $
*
Existing Coverage $
*
Max Benefit
*
Yes
Existing Coverage Type
*
Individual
Group
Elimination Period # of Days
*
Elimination Period # of Days
*
Benefit Period # of Years
*
Benefit Period # of Years
*
Business Overhead Coverage $
*
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If declined or rated, please provide details, including company.
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Cancer
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Diabetes
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*
Age at Diagnosis
*
Other Conditions
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Mental/Nervous
Respiratory
Kidney
Gastrointestinal
Cancer Type/Location
*
A1C
*
Substance Abuse
*
Drugs
Alcohol
General Questions
Select any and all that apply.
*
Personal Bankruptcy
DWI/DUI
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Hazardous Avocation
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Arrests or Violations
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