Campbell & Associates Insurance, Inc.

Business

Personal

Key Persoal Life Group Health Group Dental Group Life Group Disability 401K Other Business Services

Life Insurance Disability Long Term Care Insurance Other Individual/Family

If you are requesting a quote, it requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. If you prefer, you may contact us directly. We look forward to serving you.

Contact Information

Name:

Address:

City:

State:

Zip:

Work Phone Number:

Home Phone Number:

Fax Number:

Email Address:

Quote Information

Date of Birth:

/ /

Gender:

Male Female

Tobacco User:

No Yes

Height & Weight:

(ex: 5' 8")
(ex: 150 lbs)

Occupation:

Exact Duties:

Business Owner?:

No Yes Number of full time employees:
Office in residence?:
No Yes Number of years owned:

Current Annual Income:
(include all compensation: bonuses, dividends etc -
documentation will be required )

Is there disability coverage currently in force?:

No Yes If 'Yes', how much?

Current carrier:

Most Important?:

Cost Benefit

Desired Annual Benefit:

Desired Benefit Period:

Desired Waiting/Elimination Period:

Employer Paid?:

No Yes

Please describe any and all health conditions you have (or have had) in the past and/or any medications you are currently taking:

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your quote request.