Authorized Agent
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Blue Cross of California*
* is an Independent Licensee of the Blue Cross Association		 GERRY CACCAMO
A-ADVANTAGE INSURANCE SERVICES
Calif. Lic #OB22296

1200 E. ROUTE 66 #108 GLENDORA, CALIFORNIA 91740
800-246-3330 or 626-857-9230
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Life Insurance Quote/Private Retirement Plan


We are independents, representing licensed professionals across the United States. Our representatives shop the market for you to offer the lowest priced "A" and above rated companies in your state! Why waste YOUR TIME and MONEY with a one-company agent?
Our clients will sometimes (depending on the product) ask us to ask you to answer more questions than you might think necessary for a complete quote. However, unless you are asked (and you answer) enough questions, up-front any quote you receive might be meaningless because the price may be different after the underwriting process is completed.
So, please make it possible for us to serve you better by filling out the form as completely as possible or at least as complete as you feel comfortable with.
The information below should be filled out as completely as possible in order to receive an accurate quote and fields have an "*" in front of them are required before an agent will be in contact you.

     
    * Your Name: 
    		* Your Street or Mailing Address: 
    *City: 
    		*State: 
    * Zip: 
    		* E-mail address. 
    *Daytime Phone Number: 
    		*Evening Phone Number: 
    *These are required fields in order to process the form.

     


    Best time to call? 
    		Is this life insurance quote for you? 
    If no, then for whom?  Does the person that this rate quote is for use any type of tobacco product?

    If yes, then what type? 
    Height: Weight:
    Gender:
    		 Date Of Birth:  19
    Amount of Life Insurance you would like.
    Financial planners suggest 5 to 10 times your annual income. 
    		What type of Life Insurance would you'd like? 
    What is the primary purpose of your Life Insurance policy?

    (please mark the one that most applies) 
    Income to family in case of death. Mortgage protection Child's Education 
    Estate protection Replace existing Insurance    		 How long would you like  your 
    insurance coverage to last (what term)? 
    What is your current Life Insurance coverage amount?
    		How much is your premium per year?
    When did you last apply for Life Insurance?
    To which companies?
    What was the outcome? Accepted Declined

    Medical Information

    What are your particular health problems?
    (Please be specific in order to receive an accurate quote) 
    Do you take any medications, other than over the counter? 


    If yes, please list name and dosage:

    Have any members of your immediate family had heart disease or cancer?


    If yes, please describe

    Please press the submit button only once.



Gerry J. Caccamo · A-ADVANTAGE INSURANCE SERVICES
1200 E. Route 66 #108 · Glendora, CA 91740 · Tel: 909-592-3374 · 626-857-9230 · Fax: 626-857-9240
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