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Broker Quotes

Please complete all areas of the form as best as possible. The more accurate the information, the easier it will be for us to provide the best policy for your client. To protect your client’s privacy, first and last names are not required fields to be completed. However, we must have your name, email, and accurate phone number to contact you with your client’s quote.

FOR INSURANCE AGENTS ONLY

  • CLIENT INFO

  • If Yes, Please list dates
  • If Yes, please give details including dates
  • (Years)
  • Have any of the following occurred?
  • If Yes, please give details
  • (Date)
  • (Date)
  • If Yes, please give details
  • Yes, please give details
  • (amount/day)
  • (date)
  • If Yes, please give details
  • If Yes, please give most recent test results
  • If Yes, please give details
  • If Other, please specify
  • Please give the date and results of the most recent liver enzyme tests
  • a)AST/SGOT
  • b)ALT/SGPT
  • c)GGTP
  • If Yes, please give details
  • If Yes, please note amount and frequency
  • a) Liver Ultrasound or CT scan
  • b) Liver Biopsy
  • If Yes, please give details
  • Yes, please give details
  • Yes, please give details
  • ECG Results
  • Stress Test Results
  • Echocardiogram Results
  • Holter Monitor Results
  • Yes, please give details
  • If your client has had an abnormal kidney function test, please answer the following...
  • Yes, please give details
  • Please give most recent results of kidney function tests
  • BUN
  • Serun creatinine
  • Urinalysis
  • Please provide height and weight
  • Height
  • Weight
  • Yes, please give details
  • Yes, please give details
  • If Yes, and currently smoke (amount/day)
  • If Yes, smoked in the past but quit (date)
  • Yes, please give details
  • If yes, please give most recent results
  • What is your...
  • Height
  • Weight
  • If yes, please give details
  • If Yes, please give details
  • In Remission (list date of last exacerbation)
  • Heart Attack Date:
  • Bypass Surgery Date
  • If yes, please give details
  • If Yes - Normal (date)
  • If Yes - Abnormal (date)
  • If Yes, please give examples
  • If Yes, please give details
  • If yes, please give details
  • If Minimal Residual Impairment (please specify)
  • If Moderate Residual Impairment (please specify)
  • If Severe Residual Impairment (please specify)
  • If Yes, please give details
  • If Hospitalizations for this disorder (list dates)
  • If Surgery for this disorder (list dates)
  • If Colonoscopy (list dates of most recent)
  • Please fill out the following
  • Height
  • Weight
  • Angioplasty Date
  • Bypass Grafting Date
  • If Yes, please give details
  • If Yes, please give details
  • If Yes, please give details
  • If Yes, please give details
  • If Yes, please give dates
  • If Yes, please give details
  • If Yes, please give details
  • (also note date of last visit)
  • If Oral Medication (dose
  • If Insulin, (amount of units/day)
  • If Yes, please give details
  • If Other please explain
  • If Yes, please give details
  • What is your weight and blood pressure?
  • Weight
  • Blood Pressure
  • (date)
  • Drop files here or
    Accepted file types: pdf, doc, docx, Max. file size: 100 MB.
      .pdf, .doc, .docx only please
    • If Yes, please list dates
    • If Yes, please give details including dates
    • If Yes, please give details
    • If Yes, please give details
    • If Yes, please give details
    • If Yes, please give details
    • If Yes, please give details
    • If Yes, please indicate all that apply...
    • DESIRED COVERAGE

    • *Amount of coverage you want
    • If you are not sure about a company, leave blank and we will make a recommendation for you.

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    Excalibur Brokerage Agency,
    13 Junction Pond Lane,
    Monmouth Junction NJ 08852.
    Phone: 800-652-9923 / 732-297-6000

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