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Welcome to the GLIA Concierge Service
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HIPAA
Compliance
1
Client Information
*
This field is required.
Client's First Name
Client's Last Name
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2
Advisor's Email Address
*
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3
Gender
*
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Male
Female
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4
Tobacco Use
*
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Has your client had ANY tobacco products within 24 months, including vapor.
Tobacco
Non-Tobacco
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5
Birth Date
*
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-
Month
Day
Year
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6
Zip Code
*
This field is required.
Ex: 98765
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7
Which Product Line(s)?
*
This field is required.
Please select one per request
Life Insurance
Life/LTC Hybrid
Long-Term Care
Medicare Supplements
Annuity
Other
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8
What Type of Life Insurance?
*
This field is required.
Please select one
Term
Indexed UL
Guaranteed UL (GUL)
Whole Life
Hybrid Life/Long-Term Care
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9
Long-Term Care?
*
This field is required.
Please include a description of the desired plan design to include;
elimination period, desired daily benefit, desired benefit multiplier, etc.
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10
Annuity
Please include full description below of the desired case design to include;
desired premium amount, qualified or non-qualified, goal of your client (i.e- income, preservation, etc.), surrender period, etc
.
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11
Supplement Plan
*
This field is required.
Select up to 2 plans
Plan F
Plan G
Plan N
Other- Please specify in notes on next slide
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12
Additional information for our team?
Please include any additional information here, such as current coverage or if you think you may qualify for a household discount.
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13
Please upload any documents to assist our team with your case design including;
in-force illustrations, current coverage docs, health history, etc.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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14
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