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Disability insurance & Critical illness application setup

Email *

MKG Insurance Agency CA License No. 0J03013 | 4021 N Fresno St Ste 107 | Fresno, CA 93726 | Toll-Free 866-675-3933 | SMS Tect 559-588-4340

Is the Primary Insured a resident of California? *

Yes

Is Proposed Insured currently working at least 30 hours per week in primary occupation?

Yes

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Has any Proposed Insured been diagnosed as having, been treated or recommended for treatment by a medical professional for acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), Addison’s disease, allergies, anaphylaxis, celiac disease, chronic fatigue, colitis, Crohn’s disease, fibromyalgia, irritable bowel syndrome, lupus, multiple sclerosis (MS) Parkinson’s disease, rheumatoid arthritis, Raynaud’s disease, Kawasaki disease or immunoglobulin E, A or M (IgE, IgA, IgM)?

Yes

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Is the Proposed Insured a United States citizen or does the Proposed Insured have permanent resident status?

Yes

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Email *

Address *

Phone number

Comments

Date of Birth *

YYYY

Annual income, paycheck stub Year-to-date or W-2 most recent tax return

Is the Proposed Insured self-employed?

Primary Employer

Employer address, phone, fax and email address *

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