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ICQFIC AT A GLANCE

Health Insurance Inquiry Form----
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Example Form
Example Form

(FILL OUT THESE QUESTION & PUSH SEND)
TODAY'S DATE IS: 1.Name *
2.Address *
3.City *
4.St.Prov.
5.ZipCode *
6.WorkPhone
7.HomePhone*
8.Best Time To Have an Agent Call? *
9.Is this quote for you only?
10.If no who else?
11.Do you smoke?*
12.Height *
13.Weight *
14.Gender *
15.Age *
16.How many dependents? *
17.If Yes are they over 18? *
18.AnyHealthproblems? *
19.Any perscription medication being taken? *
20.What type of coverage do you have?
21.How much is your payment?
22.Would you like a Health or Life Quote?
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