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REQUEST A QUOTE ON A PRODUCT
McAfee Insurance Agency
Print this page, fill in your data, then fax it here
(972-938-1343) or mail it to P.O. Box 307, Waxahachie TX 75168 PUT A CHECK BY THE PRODUCTS FOR WHICH YOU SEEK A QUOTE AND FILL OUT THE SECTIONS PERTINENT TO YOUR CHOICES LIFE
INSURANCE ____
ANNUITY ____ DISABILITY INCOME ____ MEDICARE SUPPLEMENT ____ MEDICARE PLAN "D _____ LONG TERM CARE ____ GROUP LIFE, MEDICAL, DISABILITY _____
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Address_____________________________
City________________State ____ZIP______ Phone Work__________________ Phone Home _________________ Fax Number __________________ Cell Phone ___________________ Email _______________________
Date of Birth __________________
Gender_____________________ Tobacco User ____NO _____YES
Life Insurance Amount __________________
Type: ______term ______whole life ______universal life ______second to die ______not sure Height _________ Weight___________ Are you a private Pilot ________NO _________YES Occupation _____________________________ Exact Duties ______________________________ Current Annual Income ____________________
Type of Annuity:
____Flexible Premium ____Single Premium ____Immediate Tax Qualified _______NO________YES Premium Amount $__________________ Long Term Care: Daily Benefit ____________ Waiting Period_____________ Benefit Period _____________
Home Health Care __NO__YES
Spouse Name _______________________________ Spouse Date of Birth_____________________ Tobacco User _______NO______YES
Group Health Quote
Company Name _____________________ Company Address______________________ City__________________State_________ZIP_______ Type of Business______________________ SIC code___________________________ Your Name___________________________ Phone Number_________________________ Fax Number____________________________ Email ________________________________ Plan design: Doctor Visit Copay $______________ Prescription CoPay $_______________
Co-insurance________________
Group Life Insurance $_________________ Group Dental Insurance $_____________ Group Disability Insurance ______________ Any medical conditions existing with group (explain) ________________________________________ ________________________________________ Name, Date of Birth, Gender, and include this dependent code: EO, employee only; SP, employee and spouse only; CH, employee and child/children; FAM, employee and family Example: John Jones, 10-25-1975, M, FAM _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
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