Georgia life insurance, health insurance, disability and long term care insurnace from georgia-life-health-disability.com
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    •   Request a FAST Online Quotation Below!
     

     
    On-Line Long Term Care
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!

    Your Personal Data

    Your Name:
    Street Address:
    City:
    State: (Must be Georgia)
    Zip Code:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     
    Marital Status:
    Single Married
    		Are You Looking For
    Spouse Coverage?
    Yes No
     
    Health Ins. Currently?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)

    UNDERWRITING INFORMATION
     
    Insured Name: Birthdate:
    Insured Height: Insured Weight:
    Insured Occupation: Sex (M/F):
     
    Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
    Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)
     
    Any Pre-existing Health Conditions?
    		 (If yes, descibe in detail, and to which of the insured persons they apply.)
     
    Any Covered Persons Currently Taking Medication of Any Kind?
    		 (If yes, descibe in detail, and to which of the insured persons they apply.)

    COVERAGE INFORMATION
     
    How Long Do You Need Coverage For?
    (1 Year, 5 Years, Lifetime, etc.)
     
    What Daily Benefit Amount Needed? (In Dollars $)
     
    What Waiting Period Do You Want?
    (30 days, 60 days, 90 days, etc.):
     
    Any special coverages needed?
    (Such as Home Health Care Cov., Compound Inflation Rider, etc.)
     
    Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

    Send my quotation via: E-Mail Fax
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    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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    Long Term Care Quote NOW!

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    Southern Financial Consultants | 2994 Shenendoah Valley Road | Atlanta, GA 30345 | E-Mail: brucewinston@msn.com
    Phone: 404-822-3437 | Fax: 678-623-0555 | GA Ins. Lic# 707716 | Our Privacy Notice | Map/Driving Directions

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