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Life Insurance Request For Proposal

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PERSONAL PROFILE

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U.S. Citizen
Are you a stay-at-home spouse?
Do you have any other life insurance in force and/or applied for?

HEALTH PROFILE: In the last 10 years. If Yes to any questions below we will reach out for additional information.

Have you ever used tobacco, nicotine, marijuana, CBD Oil, do you vape, use e-cigarettes or smokless tabacco?
Do you have a history of anxiety, depression, or psychological counseling?
Do you have any history of Asthma, Arthritis, Cancer, Diabetes, Heart problems or Murmur, Stroke, Sleep Apnea, Melanoma?
Do you have any history of Digestive Orders: GERDS, Ulcerative Colitis, Gastritis, or Crohn's?
Within the last 10 years, have you received treatment or been advised to seek treatment for Drug or Alcohol abuse?

FAMILY HEALTH HISTORY

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Gallagher Affinity Insurance Services, Inc., provides administrative support services to insurance plans sponsored by associations and fulfilled by insurance carriers. Our support includes certificate issuance and facilitation of information in support of applications and claims for benefits provided by the insurance carrier. The carrier fulfills the benefit determination and any payments on claims associated with those benefits. Insurance brokerage and related services to be provided by Gallagher Affinity Insurance Services, Inc. (License No. 100310679 | CA License No. 0783129).

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