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Keystone Brokerage Services, LLC(dba URINSURED.COM)
URINSURED.COM P.O. Box 966, Glenside, Pennsylvania 19038

Specializing in Impaired Risk Life Insurance,
Disability & Long Term Care Planning

To receive more information about Life Insurance Coverage for someone who has suffered a
Stroke, please use one of the following methods:

  • Note:It is very important that you do your very best to provide accurate information. The more accurate the information is the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

    * Name of Proposed Insured
    * Street Address
    * City
    * State of Residence
    * Zip Code
    * Daytime Phone
    * Evening Phone
    * E-mail Address
    * Date of Birth
    * Do you smoke? (Yes or No)
    * What is your gender?
    * Height/Weight

    Amount of coverage desired:

    Type of product that you are interested in:

    Stroke Related Questions

    Date of the stroke?

    Was it a single episode or were there multiple epiosodes?

    Type of treatment or medicaton taken then and now? If medication, how much and how often?

    What tests were performed (i.i arteriography, treadmill, CT scan, etc)? Please provide details.

    What parts of the body are affected?

    Any residual impairment? Side effects? If so, please provide details.

    Any complicating factors (i.e CAD, diabetes, hypertension, etc.)? If so, please provide details.

    Was the episode (or episodes) a CVA or a TIA?

    Current medical status?

    What are the proposed insured's exercise habits?


    Family History
      AGE, IF LIVING STATE OF HEALTH,
    OR CAUSE OF DEATH
    AGE AT DEATH
    Father
    Mother
    Brother(s)
    Sister(s)

    Please click the submit button.

    Privacy Policy: We will never sell or otherwise knowingly distribute your contact information to any third party unless authorized by you to do so. You will not be contacted by phone, mail or e-mail unless you initiate the contact.

    *NOTE* - Submission of this form is neither an application for insurance coverage nor a guarantee of insurance coverage.

    Thank you.


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