EMPLOYEE INTEREST FORM
Last Name_______________________ First Name___________________
Date of Birth _____________________ Phone Number _______________
Address______________________________________________________
Dependent Children Yes No
E-mail Address_______________________________________________
Spouse’s Name:_______________________________
Spouse’s Date of Birth_________________________
Spouse’s Employer____________________ Position _______________
AVAILABLE INSURANCE POLICIES
Please check which policies you may be interested in:
YES___ NO___ Critical Illness (Heart/stroke) YES___ NO___ Hospital Plan II
YES___ NO___ Accident YES___ NO___ Cancer (Max Diff Ess)
YES___ NO___ Personal Sickness
This is not an application; it is a request for additional information and rates.
An agent will contact you.
Fax completed form to Teri Maynard @ (615) 523-1539
or scan to teri_maynard@us.aflac.com
