Life Insurance         

Your Name:

Phone Number:

Fax Number:

Email Address:

                                           Please Check All That Apply:

Requested effective date:

What type of coverage do you want?__Individual   __Individual+ Spouse   __Individual+ Child(ren)  __Full Family

Date of Birth:

Spouse’s DOB:

Gender:  ____Male or ____Female

Occupation:

Spouse’s Occupation:

Number of Children ____ Gender: M or F   Age or DOB: ___________

Does anyone use Tobacco products of any kind?______

Does anyone to be covered have any medical conditions (please list)?______________________________________________________________________________________

Does anyone take prescriptions (please list)? __________________________________________________________________________________________________________

Home City , State:

Home County :

Home zip code:

Deductibles Choices with Co-Pays an Rx: ($500 / $1,000 / $1,500 / $2,500 or $5,000)

HSA Qualified Plans:  ____Individual Deductible or ___ Family Deductible 

**Maternity is not available.  Newborns must be 14 days old to be added.  Coverage can be Denied, Rated or Ridered due to Medical Conditions.********************

**Do not cancel any current health plan before approval with this new one. *******

Did you know we can save you money on your life insurance too?  Ask me about this.

Send to Pepper Harper at fax: 214/696-3322 or pepper@rpstrategygroup.com.  

Phone us with questions 214/696-4411 ext 307 or Toll Free 1-888/234-3911 ext 307