Hansen & Associates Offers You:

First Name:	*
Last Name:	*
Middle Initial:
Address:
Apartment:
City:	*
State:	*	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Don't see your state listed?
Zip:	*
County:	*
Phone:	*	Home Office Cell
Email:	*
Periodically, we send out email communications to inform our customers of new products, special offers, and discount opportunities. May we include you on our list of recipients? * Yes No
Gender:	*	Male Female
Date of Birth:	*	In mm/dd/yyyy format. Ex.: 04/27/1965
Weight:	*	pounds
Height:	*	feet inches
If you need spouse insurance, please complete this info:
Spouse DOB:
Weight:		pounds
Height:		feet inches

When will you be purchasing insurance coverage?
1-15 days 15+ days

Do you currently have long-term care insurance?
Yes No

Answering "yes" to any of the following five questions may affect your premium or ability to obtain coverage.

Are you or your spouse a smoker? *
Yes No

Is anyone currently ill? *
Yes No

Is diagnostic testing, an operation, or any future treatment being recommended or contemplated? *
Yes No

Is anyone pregnant? *
Yes No

Is anyone taking any medication? *
Yes No

If you answered "yes" to any of the above questions, please explain:


What amount of daily benefit coverage are you considering?
$125 $150 $175 $200 $225 $250 $275 $300 $325 $350 $375 $400

Please select your preferred waiting period
(Your insurance benefits begin after your waiting period is met):
0 days 30 days 60 days 90 days 180 days

How do you prefer to pay your premiums?
single payment 10 payments monthly payments

Additional health concerns or comments: