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CAPIS LONG-TERM DISABILITY INSURANCE QUOTE REQUEST FORM
Fax this form to 213-473-8780
Name:
Member No.:                                  Medical Specialty:
Gender: Male _   Female _
Date of Birth:
Net Income (after business expenses, before taxes): $
Please list any health conditions:
Do you take any medications? Yes _   No _     If yes, please list:
Existing disability insurance? Yes _   No _     If yes, with what insurer(s)?
Monthly benefit(s) $ amount (all policies): $
Year(s) coverage issued:             Total annual premium: $
The best phone number to reach me at is: (         )
The best time to reach me is: Morning _   Afternoon _    Evening _