ANPA Group Insurance Member Benefit Survey
Please Complete This Brief Survey and Provide Any Pertinent Information Requested
1. Are you interested in ANPA Group Life Insurance and/or Own Occupation Disability Insurance?
Yes to Group Life Insurance
Yes to Own Occupation Disability Insurance
Graduate Medical Education (GME) Resident Insurance Benefits
Not Now
2. If you could only choose one or the other, would you like to receive a tax deduction now, or more tax-free income later?
I would like to receive a tax deduction now
I would like to receive a more tax free income later
3. I am interested in contributing monthly for 5 to 10 years to receive more tax-free income later.
Yes
No
Not Now
4. I would like to contribute, receive my contribution and more back during my retirement, and leave the Death Benefit to ANPA as my legacy gift.
Yes
No
Split with my family and/or other Beneficiary
5. I would like to know how to create Tax-Free income in Retirement
Yes
No
6. I would like to know more about how to protect my most valuable asset - my capacity to earn.
Yes
No
7. Do you have a Pension plan yourself?
Yes
No
8. Would you like to create a Pension plan yourself?
Yes
No
Name
Email
example@example.com
Cell Phone
Format: (000) 000-0000.
Date of Birth
/
Month
/
Day
Year
Date
Smoker / Non Smoker
Heath concerns
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