SPECIAL FOR UFCW LOCAL 1036 MEMBERS

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Full Name:
Birth Date:
Height:  feet inches
Male   Female
Weight: lbs.
Smoker Non-Smoker
E-Mail: ** REQUIRED **

 

What Type of Product are you interested in?

 

Daily benefit amount
$ ($500 max.)
Elimination Period
0 day 30 day  90 day Longer
Policy maximum
1yr 2yr 3yr 4yr 5yr 6+ Lifetime
Optional riders

Inflation Protection (Choose One Below) ** REQUIRED **
       Compound Inflation Protection
       Simple Inflation Protection
       No Inflation

Return of Premium

Survivorship Waiver of Premium

Non-forfeiture Benefit Option

How would you like home care paid?
Typically the ways to have home care paid regarding having the most options are monthly, weekly then daily. (Listed Best to Worst)

 

 

Payment Option - Your policy can be paid in full within a certain period of time. (Of course, once your policy is paid in full, there will never be any additional premiums).

Single Payment 10 Years 20 years

Paid up at age 65

If you are interested in paying your policy in full within a certain time period, choose above. Otherwise leave them blank.

Current Medications
(Name and Amount Taken)
Any hospitalization in the last 5 years. If so, what for?
 



Spouse Name:
 
Birth Date: 
Height:  feet inches
 
Male   Female
Weight: lbs.
  
Smoker Non-Smoker
 

Current Medications
(Name and Amount Taken)

Any hospitalization in the last 5 years. If so, what for?

 
Phone: (including area code)                          
** REQUIRED ** 		Fax: (including area code)
 Best time to call you  a.m. p.m.

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3069 Rikkard Drive
Thousand Oaks, CA 91362
Phone: 800-596-5947 Fax: 877-241-4435