Tomei Insurance Agency - Executive Benefits

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Executive Benefits Questionnaire

For the Fastest and most accurate quote, please provide as much information as possible. This information will be kept confidential and will be used for quote purposes ONLY!

Company Name:
Name:	Position :
Contact Name (if different):	Position :
Street Address:
	City: State: ZIP:
Email:	Fax:
Phone:
Please Contact me by:	When (Time)

PICK ONE OR MORE ITEMS OF INTEREST

401K Look alike	Executive Bonus Arrangements
Group Carve Out	Long Term Disability
Split Dollar Life	Nonqualified Deferred Compensation
Key Man Life	Buy & Sell Life & Disability
Disability Buy-Outs	Section 303 Stock Redemptions

DATA FOR ILLUSTRATION PURPOSES

Name:
Title :
Occupation :
Premium Amts:

PERSONAL INFORMATION
Date of Birth :
Gender :	Male	Male	Male	Male	Male
Gender :	Female	Female	Female	Female	Female
Marital Status :	M S	M S	M S	M S	M S
Tobacco Use :	Y N	Y N	Y N	Y N	Y N

Height :	ft. in.	ft. in.	ft. in.	ft. in.	ft. in.
Weight :	lbs	lbs	lbs	lbs	lbs

Are there any past or current health problems? If yes, please list name and provide details:

Is anyone currently taking any medications? If yes, please list name and provide details:

Has anyone been declined for health insurance? If yes, please list name and provide details:

Additional Comments

Please give any additional comments or questions

I/We would like information on the following:

IRA	How To Get Started	Stretch IRA
Mutual Funds	Keeping It In The Family	Annuity Options
Annuities	Wealth Transfer	Estate Tax Concepts
529 College Savings	Retirement Strategies	Charitable Giving
Cash Accumulation	Asset Management	Long Term Care
IRA, 401-k, 403-B, etc.. Rollovers & Strategies

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

Enter the security code you see above. Code is NOT case sensitive. *

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Tomei Insurance Agency, 223 N. Riverside Drive (Rt. 21 @ Wash St.) , Gurnee, IL 60031
Toll Free 877-336-8595, Local 847-336-8595, Fax 847-336-6598, Mail@TomeiInsurance.com, www.TomeiInsurance.com

*Securities offered through Investment Planners Inc.
Member FINRA/SIPC
226 W. Eldorado St.,
Decatur IL 62525
Tomei Insurance Agency is not affiliated with Investment Planners Inc.