Critical Illness or Accident Plans Step 1 of 3 33% Adviser Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*Phone*FaxAddress*Street*City*State*Zip CodeEmail* Client Information Name*Date of Birth*MM/DD/YYYYGender*MaleFemaleState of Residence*Tobacco Used*YesNoQuitLast Date Used*MM/DD/YYYY Medical Information Height*Feet & InchesWeight*LbsMedications and DosagesMedical HistoryHas there been a weight change of more than 10 pounds in the last year*YesNoDetails*In the last five years, has your client been treated for or received medical treatment for any of the following (Please Check all boxes that apply): High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system? Details* Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin? Details* Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system? Details* Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum? Details* Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles? Details* Disorder or condition of the back, neck or spine including “wellness” chiropractic visits? Details* Tuberculosis, allergies, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system? Details* Epilepsy, stroke, dizziness, headaches, paralysis or disorder of the brain or spinal cord? Details* Disorder of the eyes, ears, nose or throat? Details* Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorders or counseling for personal or work-related issues? Details* Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease? Details* Treatment for drug or alcohol abuse or use of any controlled substances? Details* Has your client been rated, declined or offered modified coverage from any life or health insurance carrier? Details* Visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program? Details*Have any proposed insureds’ natural parents, brothers or sisters, either living or deceased, been diagnosed prior to age 60 with any of the conditions from diabetes, heart disease, stroke, kidney disease or cancer (other than skin cancer)?*YesNoDetails* Employment Information Occupation*Income*Job Duties*Length of Employment*Work out of the home?*YesNoDetails*Does the client own their own business?*YesNoDetails including the percentage of ownership, how long the prospect has owned the business, number of employees, etc. This is important information for obtaining the best occupation class available for your client.*What is the client’s share of the monthly expenses?*What form of business?C CorpS CorpSole ProprietorshipPartnershipLLCWhat is the value of the business? Premium Budget Have you discussed a premium budget with your prospective client?YesNoWhat is it? Plan Design Is this request for Critical Illness and/or Accident Plan?* Critical Illness Accident Plan Critical Illness Amount of coverage requested*$25,000$50,000$100,000$200,000$250,000$500,000Other:If other, what is the amount of critical illness coverage requested?Critical Illness Rider options*Waiver or PremiumSpouse RiderChild RiderReturn of PremiumAccidental Death BenefitNoneAccident Plan Monthly BenefitAccident Plan Special InstructionsAccident Plan Elimination Period0 days7 days14 days16 days90 daysAccident Plan Benefit Period3 months6 months12 months24 months Upload relative documents such as financial statements, medical history, etc. FileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.