Neishloss & Fleming Inc.

Individual Medical
Group Medical
Life Insurance
Medicare Supplement

Individual Medical

Client Date of Birth: / /

Client State:

Client Zip:

Client Gender:

Male
Female

Spouse Applying?:

Spouse Date of Birth: / /

Number of Dependent Children?:

Type of Coverage Desired:

PPO
High Deductible
Short Term

How long is coverage needed?:

Tobacco Usage:

Group Medical

Company Name:

Company Contact Person:

Street Address:

City:

State:

Zip:

County:

SIC Code:

How long has the company been in business?

Worker's Comp Carrier:

Out of Area Employees?:

Requested Effective Date month and year:

Current Benefits Carrier:

Would you like a Vision quote?:

Would you like a Dental quote?:

Would you like an AD&D quote?:

Would you like to include Act 4 Coverage coverage for Dependent children through Age 29?:

Carriers Wanted? Pick all that apply:

HealthAmerica
Highmark
UPMC 10/20/40 RX
UPMC 15/30/50 RX

People:

1)

Name

Date of Birth / /

Gender

Zip

Tier

+ -

Life Insurance

What type of Life Insurance?:

Term
Final Expense
Permanent (Universal Life or Whole Life)

Client State:

Client Date of Birth: / /

Death Benefit amount in thousands:

Length of Term:

Tobacco Usage:

Currently on any Prescriptions?

If yes, please list:

Significant Medical Issues:

If yes, please list:

Immediate Family History of:
check all that apply

Stroke
Cancer
Heart Attack

Client Height: feet inches

Client Weight: pounds

Client State:

Client Date of Birth: / /

Death Benefit amount in thousands:

Tobacco Usage:

Significant Medical Issues:

If yes, please list:

Client Height: feet inches

Client Weight: pounds

Client State:

Client Date of Birth: / /

Death Benefit amount in thousands:

Tobacco Usage:

Currently on any Prescriptions?

If yes, please list:

Significant Medical Issues:

If yes, please list:

Immediate Family History of:
check all that apply

Stroke
Cancer
Heart Attack

Client Height: feet inches

Client Weight: pounds

Neishloss& Fleming Inc.

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Agent Information

What Type of Product are you inquiring about?

Individual Medical

Group Medical

Life Insurance

Medicare Supplement