MUNYAN & ASSOCIATES - Financial Consultants

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For Arizona, California, Massachusetts, Nebraska, Nevada and Texas residents only.
To ensure an accurate quote, please fill out the form below as completely as possible.

Select the type of quote(s) you would to recieve. (check all that apply)
Disability Insurance Life Insurance
Long-Term Care Insurance

First Name:
Middle Initial:
Last Name:
Address:

City:
State:
Zip Code:
Phone Number:
Fax Number:
Email Address:


*(Complete this section if requesting Life Insurance, Disability Insurance and/or Long-Term-Care Insurance)*
Gender:	Male Female
Date of Birth (mm/dd/yy):
Height:
Weight:
Tobacco Usage:	Smoked Chewed within the last 12 months
Occupation:

Describe your duties at work
Annual Income:
Amount of Insurance Required:
Monthly Coverage Desired:

Describe any health problems (leave blank if none)
List medications and dosages (leave blank if none)
Describe your family's health history of cancer and/or heart disease. (leave blank if none)


*(Complete this section if requesting Disability Insurance)*
Disability coverage should start:	90 days after disability 180 days after disability
Length of desired Disability coverage:	2 years 5 years to age 65


*(Complete this section if requesting Life Insurance)*
Type of Life Insurance Desired:	Universal Variable Term
IF TERM, Length of coverage desired:	10 years 15 years 20 years


Best time to contact you:	Day Evening

Questions / Comments

Leon Munyan is a Registered Representative offering investments through Sammons Securities Company, LLC.

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