Fentanes and Associates
Specialists in Healthcare & Financial Services
Cell
409-771-2177
Office
409-935-0303
Toll Free
866-575-8232
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First Name:
Last Name:
Home Phone:
Day Time Phone
:
Address:
City
:
State:
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Zip Code :
Who is this quote for?
Self
Spouse
Parent(s)
Child(ren)
Business Assoc.
Other
E-mail
:
Applicant:
Birth Date:
Sex
Male
Female
Smoker
Yes
No
Married
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Current employment status:
Industry that best describes your occupation:
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Full Time
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In Transition
Retired
Homemaker
Student
Other
Select One
Computers
--Graphics
--Operator/Technician
--Programmer
Engineering
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Construction
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Education
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Healthcare
--Administration
--Dentist/Dental Technician
--Lab Technician
--Nurse/Paramedic
--Pharmacist
--Physician/Surgeon
--Psychiatrist/Psychologist/Social Worker
--Hospitality/Recreation/Travel
--Airline Employee
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--Driving
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Manufacturing
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Professional
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Private Sector
--Child Care
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--Personal Assistant
Public Service
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--Government Employee
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--Justice, Public Order and Safety
--Military Officer
--National Security
--Police Department
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--Public Transportation
--Social Worker
Retail
--Auto Dealer/Service Center
--Consumer Services/Sales
--Management
--Merchandising
--Product Sales
--Security
Other-Not Listed
Retired
Self Employed
Student
Unemployed
Veteran
Has the applicant ever been declined or rated for disability insurance?
Yes
No
Do you currently have an individual disability policy?
Yes
No
If yes, please enter:
Name of company:
Monthly benefit:
Do you have a disability benefit through work?
Yes
No
If yes, please enter:
Name of company:
Weekly benefit:
Brief Health Survey
Do you take any medication?
Yes
No
Please list any medications, health issues, concerns, or comments here.
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