Your Organization:
Please Select
The Florida Bar
Florida Medical Assoc.
State Bar of Georgia
FRP - Paralegals
REALTORS-StJohns
FAMP-FL Mortgage
GODR-Neutrals
GACS-Conv. Stores
FALSS-Legal Sup
Other
Member Name:
Phone Number:
FaxNumber:
E-mail Address:
Mailing
Address:
City:
State:
Zip:
How did you hear
about us?:
Please Choose
I received an eNewsletter
I received a mail piece
I used a Search Engine (Google/Yahoo)
I was referred
I saw a print ad
I'm a current/past programs participant
Person
#1
Name:
Date of
Birth:
Gender:
Male
Female
Please choose...
Tobacco:
Never
Smoker
Smokeless Chew
Quit less than 5 yrs
ago
Quit more than 5 yrs
ago
Relation
to Bar Member:
Please choose...
Member
Spouse
Parent
Height/Weight:
4
5
6
7
ft.
0
1
2
3
4
5
6
7
8
9
10
11
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.
Person
#2
Name:
Date of
Birth:
Gender:
Male
Female
Please choose...
Tobacco:
Never
Smoker
Smokeless Chew
Quit less than 5 yrs
ago
Quit more than 5 yrs
ago
Relation
to Bar Member:
Please choose...
Member
Spouse
Parent
Height/Weight:
4
5
6
7
ft.
0
1
2
3
4
5
6
7
8
9
10
11
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 simply 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.