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Insurance Information Request Form

Term Life Quote Request

Please return via fax to 213- 473- 8780
Name:
Member No.:                                  Medical Specialty:
Gender: Male _   Female _
Date of Birth:
Have you ever used any tobacco products? Yes __   No__
Marital Status: Married __ Single__  Divorced __  Widowed __
Health conditions:

Amount of insurance desired:  $ 1 Million __   $ 2 Million __  Other: $__________

Premium Term Guarantee? 10 year  __   20 year __   30 year (if available) __
Do you currently have life insurance? Yes __   No __
If yes, do you intend to replace any existing policies? Yes __   No __

LTC Insurance Request
A separate Quote Request/Health Qualification Form will be faxed or emailed within three (3) business days.
Please indicate below how you would like your term quote sent.

Via Fax: ______________________
(please provide fax number)

Via E-mail: _____________________
(please provide e-mail address)

Via Mail: _______________________________________________________
Please return via fax to 213- 473-8780

CAP Affiliated Physicians Insurance Services - 333 S. Hope St. - 8th Floor - Los Angeles, CA 90071