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AEP
AEP Marketing Materials
Contracting
Existing Agents
Find Out More (FAQs)
Licensing Tools
New Agents
Products
Ancillary
>
Disability Insurance
Group Ancillary
Hospital Indemnity
Small Business Retirement Plans
Short-term Medical
Travel Insurance
Critical Illness
Dental, Vision & Hearing
Hybrid Life & LTC
Life & Annuities
>
Annuities
Term Life
Whole Life
LTC & Care Products
>
Long-Term Care
Home Care
Short-term Care
Medicare
>
Medicare Advantage
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Client Information
*
Indicates required field
Name of Insured
*
First
Last
Name of Co-Insured
*
First
Last
[object Object]
Date of Birth
*
Date of Birth
*
Gender
*
Male
Female
Gender
*
Female
Male
Option 3
Married
*
Yes
No
Height
*
Enter as 5'7" format.
Weight
*
State
*
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Washington D.C.
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U.S. Resident?
*
Yes
No
U.S. Citizen?
*
Yes
No
Resident Country (if not U.S.)
*
Tobacco Use
*
Yes
No
If yes, date last used.
*
Type of Tobacco Used
*
Cigarettes
Cigars
Pipe
e-Cigarettes
Chewing Tobacco
Dissolvable Tobacco
Hookah
Kreteks
Coverage Details
Daily or Monthly Benefit $
*
Home Care Rider
*
52 weeks
26 weeks
13 weeks
None
Premium Goal $
*
Benefit Period (Years)
*
360 days
270 days
180 days
90 days
Elimination Period (Days)
*
0 days
20 days
100 days
Has client ever been declined or rated for insurance?
*
Yes
No
If declined or rated, please provide details and company.
*
Medical Provider
Date Last Consulted
*
Reason for Visit
*
Current Medications
*
Diagnosis
*
Health Questions
Cancer
*
Yes
No
Diabetes
*
Type 1
Type 2
Cardiovascular
*
Heart
Stroke
High Blood Pressure
Age at Diagnosis
*
Age at Diagnosis
*
Other Conditions
*
Mental/Nervous
Respiratory
Kidney
Gastrointestinal
Cancer Type/Location
*
A1C
*
Substance Abuse
*
Drugs
Alcohol
Select if applicable.
*
Quad Cane
Wheel Chair
Walker
Scooter
Oxygen
Select if applicable.
*
Alzheimer's
Dementia
Parkinson's
Multiple Sclerosis
Lupus
COPD
Confined to a facility or received therapy in last six months?
*
Yes
No
Receiving disability benefits or eligible for Medicaid?
*
Yes
No
Other Details & Concerns
*
Agent Information
Agent
*
Phone
*
Email
*
Agency
*
City
*
State
*
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Alaska
Arizona
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California
Colorado
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Florida
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Indiana
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Michigan
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