Clemon-Maki Insurance Associates Personal, Business & Financial Coverage
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Full Name
E-mail Address
Phone Number
Best time to be reached
Street Address
City
State
Zip
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* Denotes Required Fields  
Please check the type(s) of policy you would like to apply for:
Homeowners Insurance
Date of Birth:
Marital status?
Spouse Full Name:
Do you own or rent your home?
Is this a condominimum or townhouse unit?
Business / Commercial Insurance
Name of Business:
Contact Name:
Business Street Address
City
State
Zip
Fax Number:
Current Insurance Company (Not Agency) Information
Company Name:
Policy Expiration Date:
What type of coverages do you currently have?
 No Present Coverage
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
 
Health Insurance
Date of Birth:
Smoker
Height
Weight
Health
Occupation
Number of children (18 & under)
Marital status?
spouse details
Full Name
Date of Birth
Smoker
Height
Weight
Health
Occupation
Auto Insurance
Date of Birth:
Marital status?
Spouse Full Name:
Please list other drivers in household & thier age(s)
Are any drivers full-time students with a 3.0 GPA in their last sememster of school?
Have you had any violations or accidents in the last 3 years?
Life Insurance
Date of Birth
Smoker
Marital status?
Spouse Full Name:
We offer the following types of insurance products for your family's insurance needs:

Life Insurance
Term Life - Level term plans with 5, 10, and 20 year guarantees.
Decreasing Term - To help pay off your home mortgage.
Annual Renewal Term - For short term, immediate needs.
Universal Life - Flexible secure with money market interest rates.
Traditional Whole Life - Guaranteed interest on your cash values.
Variable Life - For the sophisticated investor.
Second to Die - an excellent survivor policy for estate planning issues.

Annuities
Tax Sheltered Annuities, immediate, deferred or indexed annuity.

Long Term Care
Disability and Income Buyout Plans
Individual and Group Health

 
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