Barry J. Fisher Paradigm Insurance Marketing

AGENT INFORMATION

Marketing Contact*
---I have no contactArland SteenBarry FisherBarry SilbertDolores MarquardtKae HammondRon HalenSue RootSusan Blais

DATE*

AGENT NAME*

PHONE NUMBER*

FAX

EMAIL*

ADDRESS

CLIENT INFORMATION

STATE OF RESIDENCE
---ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVIVAWAWVWIWY

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 on Client

CLIENT (JOINT POLICY) INFORMATION

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 on Joint Client

REQUESTED BENEFIT DESIGN

Daily Benefit Amount:

Elimination Period:
---0 days30 days90 days

Benefit Period:
# of years: Lifetime 

Additional Options:
---Tax-qualifiedNon-tax-qualified

Type of Coverage:
---ComprehensiveNursing facility only

Inflection Protection:
---None5% Simple5% Compound

Payment Options:
---Annual Pay10-PaySingle Pay

Comments on requested benefit design:

Type in the text above:*