AGIS Serving Metro Milwaukee - Long Term Care Insurance

Brookfield Business List

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Primary
Name:	First: Last:
E-Mail address:
Phone numbers:	Daytime:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
Best time to call:
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:
Birthdate:
Sex:	Male Female
Rate Class:	Preferred Standard
Daily Benefit Amount:
Home Care:	50% 75% 100%
Benefit Period:	2 Years 4 Years Lifetime Other
Elimination Period (Days):	0 30 90 Other
Inflation:	Simple Compound COLI
Spouse
Name:
Birthdate:
Sex:	Male Female
Rate Class:	Preferred Standard

Duplicate Benefits From Primary?	Yes No

If no, please complete the following:
Daily Benefit Amount:
Home Care:	50% 75% 100%
Benefit Period:	2 Years 4 Years Lifetime Other
Elimination Period (Days):	0 30 90 Other
Inflation:	Simple Compound COLI
Pre-Underwriting:
Please list any additional comments, as well as any significant health conditions, associated medications AND/OR hospitalizations in the last 5 years.

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AGIS Insurance Center, Inc.
205 Bishops Way Suite 202
Brookfield, WI 53005
Phone: 262-641-9800
Email:AGIS.HOME@agisins.com

Hours of Operation:

Monday - Thursday 8:30am to 5:00 pm CST

Friday 8:30am to 4:00 pm (8:30am to 1:00pm Memorial day thru Labor Day)

Or by Appointment

image shows a house indicating homeowners insurance or home insurance a car indicating car insurance or auto insurance a computer indicating business insurance and a family holding hands indicating life insurance

AGIS Insurance Center

205 Bishops Way Suite 202

Brookfield, WI 53005

262-641-9800

888-781-2220

(Located in Bishops Woods,

Abor Terrace II building)