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HMECG Proposal
As your agent, we want to help you balance your coverage with your budget to provide Protection for Life. The Financial Snapshot is an easy way to determine your current financial position, identify areas of concern, as well as understand your hopes and dreams for the future. Please take a few minutes to answer the following questions. Please visit our website www.consultwithedmond.com.
Name *
Email *
Address *
County? *
Phone number *
Date of Birth *
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DD
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SMOKE?
Clear selection
Martial Status
Clear selection
SSN#
Employer Name
Spouse Name
Spouse Date of Birth
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DD
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YYYY
Spouse SSN#
Employer Name
Is the customer a U.S. citizen? *
Is the spouse a U.S. citizen?
Clear selection
Primary Contact: *
Preferred Mailing Address
Medicare Customer ONLY
Medicare Part A
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DD
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YYYY
Medicare Part B
MM
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DD
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Primary Care Physican *
Specialists
DEPENDENTS Information
Name, Age, DOB, and SSN
Dependent 1#
Dependents 2#
Dependent 3#
Dependent 4#
ANNUAL SALARY
Primary Income *
Spouse Income
Projected Annual Income *
Primary Employer: *
Spouse Employer:
Do you currently have health insurance at your job?
Clear selection
Health Carrier
How much do you pay?
ANYONE ON MEDICAID / MEDICARE / PEACHCARE? *
Financial Snapshot
Currently I have
Health Information
Do you have any health insurance? *
Are you satisfied with your health coverage?
Clear selection
How much per month do you currently spend on health insurance?
If you want to improve your health benefits, how much more a month are you willing to spend?
If we are able to create a package that includes health insurance; cash you need to fill gaps and cover out-of-pocket expenses; plus life insurance—how much would you be willing to spend?
Life Insurance
DO YOU CURRENTLY HAVE LIFE INSURANCE:
Clear selection
Is this temporary or permanent?
Clear selection
Carrier
Auto Insurance
DO YOU CURRENTLY HAVE AUTO/HOME INSURANCE:
Clear selection
Are you happy with your current carrier?
Clear selection
What is your current premium?
Comprehensive and Collusion or Liability?
Clear selection
Limits?
Desire Limits?
Rental Car?
Clear selection
Towing?
Clear selection
Under Insured Coverage?
Clear selection
HOME: Amount of personal property?
HOME: Do you have a burgular alarm?
Clear selection
HOME: Do you have mortgage?
Clear selection
HOME: What is your home valuation (appraised)?
DO YOU CURRENTLY HAVE RENTAL INSURANCE:
Clear selection
Are you happy with your current carrier?
Clear selection
Who is your current carrier?
What is your current premium?
Amount of personal property?
Method of payment
Clear selection
Card Number
Expiration Date
MM
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DD
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YYYY
3 Digit Code
Billing Zip
Referrals
Please submit 3 reference of individuals who could use our services. Earn $$$ for referrals. Electronic form www.tinyurl.com/referecg.
Referral 1#
Referral 2#
Referral 3#
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