CFCI Questionnaire Name* First Last Email* PhoneAge*Spouses Name (if applicable) First Last Spouse AgeDependent #1 (if applicable) First Last Dependent # 1 AgeDependent # 2 (if applicable) First Last Dependent #2 AgeDependent # 3 (if applicable) First Last Dependent # 3 AgeAdditional Family Members:Please enter any additional family members (Dependents) name and age. In what Country do you reside?* Do you currently have health insurance?*YesNoIf so, who is it through? (What is the name of the carrier?) What is the deductible?What are the current annual premiums?What is your renewal date? MM slash DD slash YYYY Do you need maternity benefits?YesNoDoes anyone in your family have a medical history that would be deemed a pre-existing condition that we need to have covered?YesNoPre-existing ConditionsPlease briefly describe any pre-exsisting conditions you or a family member needs coveredDo you want to have access to medical care in the US?YesNoHiddenDo you want information on international life insurance?YesNo
