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INFORMATION REQUEST FORM
John
Salicco

Independent Insurance Agent
Office Phone: 206-497-0049
So that I may better serve you, please tell me a little about your present situation.
*
Indicates a required information field.
When is the best time to reach you Monday through Friday.
Mornings
After noon
Please tell me about your primary area(s) of interest. Check all that
Personal needs
Business needs
Lowering company expenses or FICA taxes
Long Term Care
options
or the "CLASS Act"
Disability Insurance - personal or for
select executives and/or employees
(Executive
Carve Out).
What are your greatest personal concerns?
Using tax advantaged assets instead
of taxable funds to pay for Long Term Care
Controlling my
company's or my practice's insurance costs
Estate or asset protection for myself and/ or employees
Better safe return than a CD
- Annuity
information or rate quote
Briefly, tell me
about any other
interests or
concerns you you would like to discuss.
With an independent agent, you have more choices.

NOTE: I respect your privacy. I will not add your email
address to any other lists or provide any information about you to a third party.
All rights reserved.
Revised:
09/03/10
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