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BADER INSURANCE
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Tel 1-800-523-3111
Tel 1-413-737-3139
Fax 1-413-747-7962
info@baderinsurance.com
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Long Term Care Proposal Request
Agent/Broker Name
Agent/Broker E-mail
Agent/Broker Fax
Agent/Broker Phone
Return Method
Insurance Company
Preference (If Any)
Client Name
Client Age/DOB
Sex
Smoking
Medical Problems /
History (If Any)
Rate Class
Daily Benefit Amount
Home Care
Inflation
Riders (if any)
Spouse Name
Spouse Age/DOB
Sex
Smoking
Medical Problems /
History (If Any)
Rate Class
Duplicate Above
Spouse Benefits
If Not,
Please State Changes
Include All
Supplemental
Info Here
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Disability Proposal Request
Agent/Broker Name
Agent/Broker E-mail
Agent/Broker Fax
Agent/Broker Phone
Return Method
Insurance Company
Preference (If Any)
State Of Issue
Client Name
Client Age/DOB
Sex
Smoking
Medical Problems /
History (If Any)
Occupation
Specific Duties
Income
Premium Payment
Other Coverage
In Force
Disability Insurance
Monthly
Benefit
Or Max Available
Elimination
Period
Benefit
Period
Optional
Benefits
Business Overhead Expense
Monthly
Benefit
Elimination
Period
Benefit
Period
Optional
Benefits
Disability Buy-Out
Monthly
Benefit
Or Lump Sum Benefit
Elimination
Period
Benefit
Period
Total Coverage
Desired
Include All
Supplemental
Info Here
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Life Insurance Proposal Request
Agent/Broker Name
Agent/Broker E-mail
Agent/Broker Fax
Agent/Broker Phone
Return Method
Insurance Company
Preference (If Any)
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Annuity Proposal Request
Agent/Broker Name
Agent/Broker E-mail
Agent/Broker Fax
Agent/Broker Phone
Return Method
Annuitant Name
Annuitant Age/DOB
Sex
Joint Annuitant Name
Joint Annuitant
Age/DOB
Sex
Insurance Company
Preference (If Any)
State Of Issue
Tax Qualified
Select One Of The Following Annuity Products
Single Premium Deferred
Single Premium
Deposit
Flexible Premium Deferred
Flexible Premium
Deposit
Indexed Annuity
Indexed
Deposit
Single Premium Immediate
Single Premium
Deposit
Or Modal
Benefit
If Modal Benefit
Life
Only
Life And
Years Certain
Years
Certain Only
Installment
Refund
Describe Medical
Conditions & Any
Supplemental
Info Here