1233 N Mayfair Rd # 104, Milwaukee, WI
Phone: (414) 453-6181 – Fax: (414) 453-0080 –
agents@macgillisandcompany.com
Home
|
Personal Insurance
|
Financial Insurance
|
Business Insurance
|
24/7 Claim Service
|
Contact
Financial Insurance
Contact Information
Name:
Phone Number:
Email:
Preferred Method of Contact:
Select...
Email
Phone
Preferred Time of Day to Call:
Select...
Morning
Evenings
Weekends
Question/Comment:
Individual Health Insurance
Type:
Select...
Permanent
Short Term Medical (Up to 360 days)
Date of Birth:
ZIP Code:
Sex:
Select...
Male
Female
Height:
Weight:
Smoker / Non-Smoker:
Select...
Smoker
Non-Smoker
Pre-Existing Conditions:
Deductible:
Family Members:
Group Health Insurance
Name
Sex
Date of Birth
Participant 1:
Select...
Male
Female
Participant 2:
Select...
Male
Female
Participant 3:
Select...
Male
Female
Class:
Select...
Single
Employee & Spouse
Employee, Spouse & Children
Employee & Children
Current Carrier:
(Please
email
a copy of your census report if available.)
Life Insurance
Type:
Select...
Term
Permanent
Amount of Coverage Desired:
Length of Term:
Date of Birth:
Height:
Weight:
Smoker / Non-Smoker:
Select...
Smoker
Non-Smoker
Any health issues:
Long-Term Care Health Insurance
Name:
Date of Birth:
Limits of Coverage:
Any health issues:
Medicare Supplemental Insurance
Date of Birth:
Medicare Part A & Part B effective date:
ZIP Code:
Any health issues:
Drug Plan Insurance
(Written along with Medicare Supplements)
Annuities
Amount of Annunity:
1035 Exchange?
Plan:
Select...
Single Premium Retirement Annuity
Deferred Annuity
Immediate Annuity
Date of Birth:
Anti-Spam Question:
(Required)
Is water wet or dry?
