Insurance Brokers & Consultants

Affordable Insurance Solutions	info@pennhurst.com 215-918-2037

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Professional Liability

Health Insurance

Long Term Care
Insurance

Low Cost Term Life
Insurance

Insurance Information

Professional Liability

General PPO

Benefits of Long Term Care Insurance

Disability Insurance Quote Request

Nearly one-third of all Americans between the ages of 35 and 60 suffer an injury or sickness that keeps them from working for at least 90 days. What would happen to YOUR household or YOUR business if YOUR paycheck stopped ?

Fill in all fields and then click the Submit button to send your request. You can also print out this form, fill it out, and fax it to us at 215-918-2872.

Full Street Address:

City:

State:

Zip Code:

Phone: (Incl. Area Code)

Best Time to Contact You: AM PM

Fax: (Incl. Area Code)

Email Address:

Date of Birth:(ex. 01/01/70 )

Gender: Male Female
Tobacco Use: Yes No

Occupation:

Duties:

Monthly Salary: ( in Dollars )
$

If self-employed, your personal net average monthly income: ( in Dollars )
$

If business owner, how long have you been in business:
years

Percentage of manual duties:
%

Number of Employees:
%

If in sales:

Percentage of travel:
%

Average annual income during the past 2 years:
$

Any health problems
Yes No

If yes, please describe:

Special Notes ( ie. other coverage):

Home Based Business:
Yes No

Monthly Benefit Desired: ( in Dollars )
$

Benefit Period:
1 year 2 years 5 years Till age 65

Waiting Period - this is a period that no benefits are paid. The longer the waiting period, the lower the cost.
30 days 60 days 90 days 180 days 365 days

Insurance Quotes: Professional Liability | Health Insurance | Long Term Care Insurance | Low Cost Term Life Insurance

Insurance Information: Professional Liability | General PPO | Benefits of Long Term Care Insurance