Name*
Address*
City*
State *
Telephone *
Email *
1: My compensation is based on: Fees       Commissions       Both
2: Do you have a Broker Dealer?: Yes       No
      If Yes, are you allowed to conduct insurance business outside of your Broker Dealer?:
      Yes       No
3: Do you offer long-term care insurance now?: Yes       No
      If Yes, please list carriers you are licensed to represent:
     
4: Do you refer long-term care business to outside agents?: Yes       No

 

Please feel free to call Gerald Summers CFP®, CLU®, ChFC®, CASL™
at 888-533-7503 if you require assistance.

Thank you.

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