Specialty Products and Programs Step 1 of 3 33% Agent Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*PhoneFaxAddress*Street*City*State*Zip CodeEmail* Client Information Name*Date of Birth*MM/DD/YYYGender*MaleFemaleState of Residence*Tobacco Used*YesNoQuitLast Date Used* Medical Information Height*Feet & InchesWeight*LbsMedications and DosagesHas 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* Case Details Case InformationPlease provide information which may assist in generating an accurate illustration including information on special travel, avocations or hobbies, special work circumstances or history, etc. Request A Proposal For: High Limit Accident Only Major Medical Traveling Abroad Failure to Perform Athletes Kidnap and Ransom Special Travel Risk Divorce, Alimony and Child Support Severance Payment Coverage Student Loan Protection What is High Limit Accident Only?Traditional Life and Disability Insurance policies can leave many gaps in a person’s insurance protection plan. Whether those shortcomings are from benefit limits or policy exclusions, High-Limit Accident Only plans can fill those gaps and protect a group or an individual against the financial devastation that a death or permanent disability can create.What is Major Medical Traveling Abroad?Throughout 2013, don’t hesitate to remind your clients to purchase travel medical insurance for any excursions outside the United States. You may be shocked to know that traditional American medical insurance policies provide little coverage outside the U.S. The HMO or PPO plan you have dutifully provided your clients may allow for sufficient coverage through most of the year, but if your clients travel past our borders, benefits are commonly limited to emergency coverage only. Other plans limit benefits to only $50,000. And if your client is a senior citizen, the purchase of an additional Medicare supplement is required to provide limited-benefit medical insurance outside the U.S. The plan is GUARANTEED ISSUE for anyone under the age of 85 and provides up to $5,000,000 of benefits including non-emergency medical expenses, emergency medical expenses, prescription medications, medical evacuation services and many other travel insurance benefits.What is Failure to Perform?What is Athletes?Many sports fans and members of the public believe professional football players are so lucky! The players often sign large contracts to play the game they love and then their worries are over. Right? Wrong! The reality is that professional football has some of the least guaranteed contracts of any major professional sports. This income could have been protected with a disability insurance policy, but most likely it was not because many players think, I will never get sick or hurt or I don't want to waste the money. What is Kidnap and Ransom?Kidnap and ransom insurance should be considered more widely by travelers. Of course, individuals should protect themselves, but so should businesses and corporations, doctor groups, educational institutions, missionary groups, financial institutions, athletic teams, film productions, boating enterprises, private plane charters and many others. By obtaining this type of insurance, travelers are covered for kidnapping, extortion, detention and hijacking. Over the past several months, our firm has seen a significant increase in kidnap and ransom plan sales, as many agents have started recognizing the travel patterns of their clients and have begun to advise them of this coverage.What is Special Travel Risk?What is Divorce, Alimony and Child Support?What is Severance Payment Coverage?What is Student Loan Protection?Would you like our Marketing Team to suggest the one carrier we feel provides the best value for your client? If you select no, multiple quotes will be provided.*YesNo Attach financial statements, existing policies, medical records, etc. FileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.