EASC/Dodd Brokerage

1181 Noe Bixby Rd
Columbus, OH 43213
614-863-3633 800-862-0085 Fax 614-863-0205

Ancilliary Insurance Products

Life Quote Request Form
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Dodd Brokerage
Phone: 614-863-3633 Toll Free: 800-862-0085 Fax: 614-863-0205

Agent: Phone:
Fax: Email:

	Date of Birth:	Height	Weight	Have you used tobacco products in the last 12 months?
Client 1:
Client 2:

1. Do you have symptoms of or have you received medical advice, diagnosis or treatment, or consulted with a member of the medical profession for any of the following conditions within the last fives years?

	Client 1	Client 2		Client 1	Client 2		Client 1	Client 2
Heart Disease			Bowel Disorders			Reproductive Disorders
Coronary Artery Disease			Bladder Disorders			Respiratory Disorders
Circulatory Disorders			Prostate Disorder			Parkinson's Disease
High Blood Pressure			Kidney Disorder			Seizure
Leukemia			Depression			Tremor
Lymphoma			Alcoholism			Diabetes
Cancer			Liver Disorder			Alzheimer's Disease
Paralysis			Osteoporosis			Dementia
Stroke, TIA			Arthritis			Memory Loss

		Client 1	Client 2
2.	Within the last 5 years, have you been hospitalized or consulted or been treated by a member of the medical profession for any reason not Previously stated?
3.	Do you currently use any assistive or mechanical devices?
4.	Have you ever received home health care or been confined to a nursing home or rehabilitation facility?
5.	Do you currently need or receive any help in doing any of your activities of daily living?

Details:

Question #		Date of Onset
Details
Question #		Date of Onset
Details
Question #		Date of Onset
Details
Question #		Date of Onset
Details

Medications:
Medications:

LTC Benefit Description	Client 1	Client 2
Daily Benefit
Elimination
Inflation Option
Benefit Period

Life and Long Term Care Combo	Client 1	Client 2
Death Benefit Amt (Quoted as Guaranteed Death Benefit with No Lapse Premium)
Long Term Care Rider Amt (This rider can be issued for up to 100% of the Death Benefit)