Pension Planners of West Texas

Please complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

Contact Information
Name:
Address: Address2: :
City:	State: Zip:
Phone:	Work:
	Home:
	Fax:
Email Address:

Quote Information
Date of Birth:	//
Gender:	Male Female
Smoker?:	Yes No
Height & Weight:	(ex: 5' 8") (ex: 150 lbs)
Daily Benefit ($50 - $500):
Waiting Period (0 - 365):
Benefit Period:	3 years 5 years 10 years Lifetime
Include Home Health Care Coverage?:	No Yes
Include Inflation Protection?:	No Yes
Please describe any and all health conditions that resulted in hospitalization and/or surgery in the past 10 years:

Spouse/Companion Information
Relationship?:	Spouse Companion
Name:
Gender:	Male Female
Date of Birth:	//

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your quote request.