Individual Client Form   Current Insurance Coverage? Yes: or No: If so, name of current insurance carrier? Current Insurance in place: Health , Dental , Vision , Life Desired Insurance Coverage: Health , Dental , Vision , Life Are you interested in Short or Long Term Insurance coverage? Long-Term or Short-Term   Name of each person to be insured DOB Gender Relationship to Insured . Resident Zip Code Est. Ann. Salary (For Life & Disability only) Occupation (For Disability) 1: Male Female 2: Male Female 3: Male Female 4: Male Female 5: Male Female   Back   © 2006. Talec Group Insurance Services, Inc. All Rights Reserved.