ࡱ> @B?5@ bjbj22 ,4XX U&&&: 4 L:.DDDD*,,,,,,$aRP&2"22PDDEe28D&D*2*Pj&jD" 0a*X N@jF{0jMpMj::M&j YPP:: :: Engel Agency, Inc. Fax #(847) 478-8600 E-Mail:  HYPERLINK "mailto:paul@engelagency.com" paul@engelagency.com REQUEST FOR LIFE, LONG-TERM CARE AND DISABILITY INCOME ILLUSTRATIONS Applicant_______________________________ Date of birth___/___/___ Gender: M ___ F ___ Spouse______________________________ Date of birth___/___/___ Occupational Duties______________________________________________________ Spouses Occupational Duties_______________________________________________ Net Annual Income_____________________Spouse____________________________ Resident State_________ Tobacco Use: Never___ Former (date quit)___/___ Current___ Spouse: Never___ Former (date quit)___/___ Current___ Applicants Height: ___ft. ___in. Applicants Weight: ______ Spouses Height: ___ft. ___in. Spouses Weight: ______ Past Five Years Applicant: Medications & dosage_____________________________________________________ Treatments______________________________________________________________ Therapies_______________________________________________________________ Date of Last Doctor Visit_____________ Past Five Years Spouse: Medication & dosage_____________________________________________________ Treatments_____________________________________________________________ Therapies______________________________________________________________ Date of Last Doctor Visit___________ Do you own your own business Y/N Form of Business Structure: S-Corp ______ C-Corp ______ Other_______________________ Do you or your spouse have a family member or friend who has received long-term care? Yes ___ No ___ Request for Benefit Illustration for: LIFE INSURANCE DISABILITY LONG-TERM CARE Amount of Coverage _____________________________ Daily Benefit _____________________________ Waiting Period 0, 30, 90+ ____________________________ Term Period 10, 15, 20, 25, 30, + _____________________________ Benefit Period _____________________________ Monthly Benefit $3K, $4K, $5K ____________________________ Replacing Coverage? _____________________________ Elimination Period (60, 90, 180) _____________________________ Benefit Period 5yr, 10yr, Life ____________________________ Disability Premium Waiver? Yes or No _____________________________ Inflation Protection? Yes or No _____________________________ Return of Premium? Yes or No ____________________________ Return of Premium Rider? Yes or No _____________________________  PLEASE MAKE A COPY OF THIS FORM, FILL IT IN AND THEN FAX OR E-MAIL TO ENGEL AGENCY  45^_`tuvw¸ulclZlclclcQlLG h:{5 h<5h%A5CJaJh5a5CJaJhP5CJaJh:{5CJaJhKh/5B*phh+h/0J5'jh+h/5B*Uphh/5B*phjh/5B*UphhK5B*phhP5B*CJ(aJ(ph hKh)5B*CJ(aJ(ph hKhP5B*CJ(aJ(phjh/UmHnHuvw V 4 L `0dh]`^0gdzs `0]`^0gd< `0]`^0gdzs ``]`^`gd)-$h$d%d&d'dNOPQ]ha$gdK$``]`^`a$gd)      T U V 4 B K L W X Y Z [ ` c d e m v ~    & 0 1 5 < ? 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Preferred CustomerSara E. Zawacki10)2D%AP'-x/2?4`8 OQPpSJXdZg_[d\^Z_5a ozsMxN|j7M(;zZDP\l)9l M<K:{C`QO DUomHkN/-de @= w x  "@  @{ @@UnknownGz Times New Roman5Symbol3& z Arial"h0Bf+fFARoot Entry F**XCData 1Table#MWordDocument,4SummaryInformation(/DocumentSummaryInformation87CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q