Complete the form below to receive a quote
on your insurance needs.
Type of Insurance:
(check as many as apply)		  Individual Health
 Medicare Supplements
 Long Term Care
 Life Insurance
 Disability
Personal Information
First Name   Birthdate mm/dd/yy
Last Name   I am a:  Smoker
 Non-Smoker
Street Address   Height ft. in.
City   Weight lbs.
State Zip   Gender Male
Female
Email Address Phone Number
Health Information
I would describe
my overall health as: 		 Excellent
 Good
 Poor 		Are you currently pregnant? Yes
No
Is there any
prescription medication
you take regularly? 		Yes - Medication Names:
No
Have you had any of
these medical conditions
in the last five years?
(Check all that apply) 		Allergies
Asthma
Cancer
Depression
Diabetes
Heart Attack/Disease
High Blood Pressure
High Cholesterol
HIV
Stroke
Other
Additional Family Members
Are there others in your family that you would like coverage included for? Provide information below for each.
Spouse
Dependent 		Full Name Birthdate mm/dd/yy
Please briefly list any medical conditions and/or medications for this individual:
Dependent Full Name Birthdate mm/dd/yy
Please briefly list any medical conditions and/or medications for this individual:
Dependent Full Name Birthdate mm/dd/yy
Please briefly list any medical conditions and/or medications for this individual:
Dependent Full Name Birthdate mm/dd/yy
Please briefly list any medical conditions and/or medications for this individual:
Any other information or comments:

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Over 50 years of experience serving the Wooster, Ohio area
with their life, health, disability, long term care and supplemental insurance needs.
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Leonard H. Abrams
Chartered Financial Consultant
Robert P. Hunt
Certified Senior Advisor