BJFIM/Paradigm Insurance Marketing
6800 Owensmouth Avenue Suite 410
Canoga Park, California 91303
Tel: (818) 883-8700 x201 Fax: (818) 883-9036
Email: info@paradigmins.com
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Proposal Request
PRINT VERSION
   
Marketing Contact:
DATE:
AGENT NAME:
TELEPHONE:
FAX:
EMAIL:
ADDRESS:
 
 
CLIENT State of Residence: California Arizona Colorado Nevada
NAME:
DATE OF BIRTH:
HEIGHT:
WEIGHT:
CURRENT MEDICATIONS:
(list name of medication and dosage)

DO YOU USE A CANE,
WALKER OR WHEELCHAIR: 		yes no

DURING THE PAST 12 MONTHS,
HAVE YOU USED TOBACCO: 		yes no

INDICATE IF YOU HAVE YOU BEEN MEDICALLY DIAGNOSED OR TREATED FOR ANY OF THE CONDITIONS NOTED BELOW:
Abnormal Blood Pressure yes no
Heart or Circulatory Disorder yes no
Chronic Respiratory Disorder yes no
Falling or Unstable Gait yes no
Confusion or Memory Loss yes no
Bladder or Bowel Control yes no
Neurological Disorder yes no
Weakness or Fatigue yes no
Dizziness or Fainting yes no
Stroke or TIA yes no
Cancer yes no
Diabetes yes no
Comments
 
CLIENT (joint policy)  
NAME:
DATE OF BIRTH:
HEIGHT:
WEIGHT:
CURRENT MEDICATIONS:
(list name of medication and dosage)

DO YOU USE A CANE,
WALKER OR WHEELCHAIR: 		yes no

DURING THE PAST 12 MONTHS,
HAVE YOU USED TOBACCO: 		yes no

INDICATE IF YOU HAVE YOU BEEN MEDICALLY DIAGNOSED OR TREATED FOR ANY OF THE CONDITIONS NOTED BELOW:
Abnormal Blood Pressure yes no
Heart or Circulatory Disorder yes no
Chronic Respiratory Disorder yes no
Falling or Unstable Gait yes no
Confusion or Memory Loss yes no
Bladder or Bowel Control yes no
Neurological Disorder yes no
Weakness or Fatigue yes no
Dizziness or Fainting yes no
Stroke or TIA yes no
Cancer yes no
Diabetes yes no
Comments
 
REQUESTED BENEFIT DESIGN:
Daily Benefit Amount:
Elimination Period:
Benefit Period: # of years: Lifetime:
Additional Options:
Type of Coverage:
Inflation Protection:
Payment Options:
Comments

(Type in the text above)
   
 
Copyright © 2006 Barry J. Fisher Insurance Marketing, Inc., is a registered trademark of Barry J. Fisher. All other names and terms in this release are trademarks or registered trademarks of their respective companies.