The Miramar Group

For immediate assistance, call us at 847-289-0077

*** GetMED 360 Changes *** *** PPO Network added to FirstChoice *** *** Core Value still accepts Certificates of Credible Coverage ***

Guaranteed Issue Medical Plans

Agent Request for Proposal

Energy and Telecom Brokerage

Experienced underwriting and marketing support give you a distinct advantage in an increasingly competitive market place! Just fill out this request form and click the "Submit form" button. Please note, all fields are required except for family information, when applicable, and Special Remarks.

AGENT INFORMATION
Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:

PROSPECT INFORMATION
Name:
Age:
Occupation:
Sex:	Male Female
Use tobacco?	No Yes
Spouse?	No Yes
Spouse age:
Spouse Occupation:
Spouse use tobacco?	No Yes
Number of children:

POLICY SPECIFICS
State of sale:
County:	(if applicable)
Zip code:
Deductible desired:
Plan desired:
Send result via:	Fax E-mail

SPECIAL REMARKS / INSTRUCTION / HEALTH CONCERNS