FL Bar Member #:
Phone Number:
Fax Number:
E-mail Address:
Mailing Address:
City:
State:
Zip:
How did you hear about us?:
 
Person #1
Name:
Date of Birth:
Gender:
Tobacco:
Relation to Bar Member:
Height/Weight:

ft. inches

lbs.

Are you currently taking any prescription medications? If yes, Name, Dosage, How long and for what condition(s).

Do you currently have or have you ever had in the past any serious medical problems such as: Diabetes, Cancer, Heart Problems, Stroke, or Osteoporosis? If so, need to know details such as when, treatment, and current status.

Important Disclaimer: This is NOT an application for insurance. This is an information gathering tool by which we can generate accurate premium quotations and make recommendations for long term care insurance. No insurance will go into effect until after you complete an actual application to an insurer, pay your first premium, and are approved by the insurer.
Person #2
Name:
Date of Birth:
Gender:
Tobacco:
Relation to Bar Member:
Height/Weight:

ft. inches

lbs.

Are you currently taking any prescription medications? If yes, Name, Dosage, How long and for what condition(s).

Do you currently have or have you ever had in the past any serious medical problems such as: Diabetes, Cancer, Heart Problems, Stroke, or Osteoporosis? If so, need to know details such as when, treatment, and current status.

Important Disclaimer: This is NOT an application for insurance. This is an information gathering tool by which we can generate accurate premium quotations and make recommendations for long term care insurance. No insurance will go into effect until after you complete an actual application to an insurer, pay your first premium, and are approved by the insurer.