Winter Insurance Agency, inc.
3773 Cherry Creek North Drive
Suite 575 , Denver, CO 80209
Phone:(303) 664-9974 Fax: (303) 664.9241
Email:info@winter-insurance.com

Prospective Client Questionnaire

  1. How did you hear about us?
Another agent Friend or Relative
Yellow Pages Internet / Web
Newspaper  
 
   
  2. Have you seen a doctor in the last 5 years? No    Yes  
  3. Are you currently under a doctor’s care? No    Yes  
  4. Do you take any major medications? No    Yes  
  5. Are you a smoker? No    Yes  
  6. Are you currently covered by any insurance? No    Yes    Company
  7. Do you need coverage such as...?
Maternity    Dental   Vision   Prescriptions  Chiropractic   Acupuncture   Other
  8. Age and sex of each insured, including yourself. 1. Age Male Female  
    2. Age Male Female  
    3. Age Male Female  
    4. Age Male Female  
    5. Age Male Female  
    6. Age Male Female  

Personal Information
  Last name First name  
  Address Apt.
  City Zip  
  Phone: Work/Day Home  
  Email Address  

Do you need any other type of insurance such as...?

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