Alaskan Benefit Insurance Consultants

1) Name (required)

2) Address (required)

3) City (required)

4) State (required)
Alaska

5) Zip Code (required)

6) Phone (required)

7) Fax

8) E-mail Address (required)

9) Sex (required)
 M F

10) Smoke (required)
 Yes No

11) DOBMM-DD-YY (required)

12) Height #'& #": (required)

13) Weight: (required)

14) Major Health Conditions or medications for all family members?: (required)

15) Spouse Info:
 M F

16) DOBMM-DD-YY

17) Smoke
 Yes No

18) Height #'& #":

19) Weight:

20) Children DOB'S MONTH / YEAR, SEX M/F:

21) Deductible:
 500 to 5,000  1,000 to 25,000  Variety of choices  HSA DEDUCTIBLES

22) Desired Effective Date MM/YEAR: (required)

23) Type of Insurance Desired: Check all that apply.(required)
 Health Savings Account HSA  Maternity  Dental  Vision  Disability  Life  Supplemental Accident Long Term Care  Medicare Supplement  International Health Plans  HEALTH INSURANCE Annuity  Short Term Coverage

24) Coverage choices
 Health  Maternity  Dental  Vision  Supplemental Accident  International Health Plan

25)  Medicare Supplement Plan Letter

26)  Short Term Coverage
# Months

27)  Life Insurance
Desired amount of coverage? $

28)  Accidental Death  Spouse Rider  Child/Children Rider

29)  Level Term # years

 Return of Premium Term

30)  Universal Life Whole Life

31)  Student Pilot
 yes no
Hazardous Activities  yes  no

If yes, please explain activity

32) Long Term Care  Yes No

33) Desired Daily/Monthly Coverage Amount
$

34) Benefit Period
 3 year 5 year Lifetime

35)  Home Health Care
 yes no

36) Waiting Period # Days

37)  Disability

38) Job Description

 Owner Employee

39) Last Years Gross Income $

40) Desired Coverage Period
 3 year 5 year Till Age 65-67

41) Desired Amount of Coverage $
Not to exceed 2/3 gross

42) Elimination Period/Deductible
 30 60 90 180 365 Days

43)  Annuity

44) Desired Amount $

45) Distribution Options
 Specified Period
#Years  Lifetime