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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.
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Name *
Email *
Address *
County? *
Phone number *
Date of Birth *
MM
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DD
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YYYY
SMOKE?
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Martial Status
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SSN#
Employer Name
Spouse Name
Spouse Date of Birth
MM
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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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YYYY
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?
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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?
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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:
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Is this temporary or permanent?
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Carrier
Auto Insurance
DO YOU CURRENTLY HAVE AUTO/HOME INSURANCE:
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Are you happy with your current carrier?
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What is your current premium?
Comprehensive and Collusion or Liability?
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Limits?
Desire Limits?
Rental Car?
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Towing?
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Under Insured Coverage?
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HOME: Amount of personal property?
HOME: Do you have a burgular alarm?
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HOME: Do you have mortgage?
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HOME: What is your home valuation (appraised)?
DO YOU CURRENTLY HAVE RENTAL INSURANCE:
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Are you happy with your current carrier?
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Who is your current carrier?
What is your current premium?
Amount of personal property?
Method of payment
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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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