Critical Illness or Accident Plans Step 1 of 3 33% Adviser Information Adviser InformationAre you new to working with Secura Consultants?*YesNoAre you new to working with Secura Consultants?Adviser Name*Adviser NameCompany Name*Company NamePhone*PhoneFaxFaxAddress*StreetAddress*City*State*Zip CodeEmail* Email Client Information Client InformationName*NameDate of Birth*MM/DD/YYYYDate of BirthGender*MaleFemaleGenderState of Residence*State of ResidenceTobacco Used*YesNoQuitTobacco UsedLast Date Used*MM/DD/YYYYLast Date Used Medical Information Medical InformationHeight*Feet & InchesHeightWeight*LbsWeightMedications and DosagesMedications and DosagesMedical HistoryMedical HistoryHas there been a weight change of more than 10 pounds in the last year*YesNoHas there been a weight change of more than 10 pounds in the last yearDetails*DetailsIn 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? 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):Details*Details Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin? Details*Details Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system? Details*Details Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum? Details*Details Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles? Details*Details Disorder or condition of the back, neck or spine including “wellness” chiropractic visits? Details*Details Tuberculosis, allergies, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system? Details*Details Epilepsy, stroke, dizziness, headaches, paralysis or disorder of the brain or spinal cord? Details*Details Disorder of the eyes, ears, nose or throat? Details*Details Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorders or counseling for personal or work-related issues? Details*Details Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease? Details*Details Treatment for drug or alcohol abuse or use of any controlled substances? Details*Details Has your client been rated, declined or offered modified coverage from any life or health insurance carrier? Details*Details Visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program? Details*DetailsHave 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)?*YesNoHave 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)?Details*Details Employment Information Employment InformationOccupation*OccupationIncome*IncomeJob Duties*Job DutiesLength of Employment*Length of EmploymentWork out of the home?*YesNoWork out of the home?Details*DetailsDoes the client own their own business?*YesNoDoes the client own their own business?Details 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.*Details 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 is the client’s share of the monthly expenses?What form of business?C CorpS CorpSole ProprietorshipPartnershipLLCWhat form of business?What is the value of the business?What is the value of the business? Plan Design Plan DesignIs this request for Critical Illness and/or Accident Plan?* Critical Illness Accident Plan Is this request for Critical Illness and/or Accident Plan?Critical Illness Amount of coverage requested*$25,000$50,000$100,000$200,000$250,000$500,000Other:Critical Illness Amount of coverage requestedIf other, what is the amount of critical illness coverage requested?If other, what is the amount of critical illness coverage requested?Critical Illness Rider options*Waiver or PremiumSpouse RiderChild RiderReturn of PremiumAccidental Death BenefitNoneCritical Illness Rider optionsAccident Plan Monthly BenefitAccident Plan Monthly BenefitAccident Plan Special InstructionsAccident Plan Special InstructionsAccident Plan Elimination Period0 days7 days14 days16 days90 daysAccident Plan Elimination PeriodAccident Plan Benefit Period3 months6 months12 months24 monthsAccident Plan Benefit Period Upload relative documents such as financial statements, medical history, etc. Upload relative documents such as financial statements, medical history, etc.FileFileFileFileFileFileFileFileFileFileCaptchaCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.
