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Sterling Healthcare Physician Insurance Questionnaire
For Help Call (469) 633-0183
Fields marked (
*
) are mandatory.
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Please select
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Zipcode
*
Daytime Phone
*
Evening Phone
Fax
E Mail Address
Health Insurance
Current Health Insurance Provider
Expiration date of current policy (If applicable)
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Premium
Deductible
Coinsurance
Plan
Family
Single
Maternity
No
Yes
Proposed Insured
Sex
Female
Male
DOB/Age
Smoker
No
Yes
Spouse
Sex
Female
Male
DOB/Age
Smoker
No
Yes
Children(s), Sex, DOB/Age
Disability Insurance
Current Carrier
Monthly Benefits
Premium
Current Carrier
Monthly Benefits
Premium
Current Carrier
Monthly Benefits
Premium
Life Insurance
Current Carrier
Benefit Amount
Type of Coverage: Term, UL, VUL
Current Carrier
Benefit Amount
Type of Coverage: Term, UL, VUL
Current Carrier
Benefit Amount
Type of Coverage: Term, UL, VUL
Long Term Care Insurance
Do you currently have Long Term Care Coverage?
No
Yes
What type of Plan (Indemnity, Reimbursement)?
Current Carrier:
Monthly/Daily Benefit:
Retirement Plan
Do you currently have a Retirement Plan in Place?
No
Yes
What type of Plan (401k, Annuity, IRA, etc)?
How much would you like to save per year?
Are you interested in saving for retirement on a pre-tax basis?
No
Yes