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AEP
Contracting
Existing Agents
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
Medicare Supplement
Part D
Carriers
Carrier Selection
Forms & Materials
Incentives & Trips
Webinars
Quoting & Apps
Electronic Apps
iGo e-App
Medicare Center
Quote Requests
Quoting Tools
Underwriting
Marketing
Brochures
Email & Mail
Fact Sheets
Leads & Prospecting
Logos
Seminars & Webinars
Social Media
Websites
Tools & Training
Education & Training
Medicare Live
Secure File Upload
Tips of the Trade
Video Conference
News
COVID19
Industry Resources
The Resource (Blog)
About
Contact
Find Out More (FAQs)
Meet the Team
Testimonials
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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Submit
