Cover Sheet For All Correspondence ‐ Mail or Fax

Cover Sheet For All Correspondence ‐ Mail or Fax
Date: ______________________________ Number of pages including cover sheet: ____________
Attention: _________________________________________________________________________________
Fax Information/Special Instructions: ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Person to contact for additional information: ____________________________________________________
Agent Name: _____________________________
Phone Number: ___________________________ Fax Number: ________________________________
Has the Paramed Exam been scheduled?
Yes
____
No ____
Company Name: _______________________________________________
Do you want us to call in the Paramed Exam? Yes _____
APPLICATION COMPLETION TIPS
‐ SUBMIT A COMPLETE AND ACCURATE APPLICATION WITH SUPPLEMENTAL FORMS.
‐ Insured/Owner and all additional insured MUST sign.
‐ Use permanent BLACK INK.
‐ LEGIBLY print in English.
‐ NO white out. Any changes to written answers must be initialed by applicant/proposed insured.
‐ Address to include street, city, state and zip code (all numbers legible).
‐ BENEICIARY ‐ Provide given name of beneficiary and relationship.
Fax: 888‐799‐8995
Overnight Applications to:
Arizona Life & Annuity Brokers
1270 N. Broadway Rd #112
Tempe, AZ 85282
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