Life and Health Insurance Foundation for Education



realLIFEstories® 2010 Client Service Awards Application Form

Learn more about realLIFEstories here
You can also download a PDF version here

Required fields are indicated by an asterisk (*)

ABOUT YOU:


CASL
CLU
CFP
CPCU
CLTC
ChFC
FSS
FLMI
HIA
LUTCF
REBC
RHU
Other

Yes No
AALU
FPA
GAMA Intl
IIABA
Intl. Forum
MDRT
NAHU
NAIFA
PIA
SFSP
Other

YOUR STORY:

1. What category of insurance is your story?
Individual Life Insurance
Which of the following does your story involve?
Death Benefits Living Needs Benefits Business Continuation
(Top 2 stories will be chosen from this category)
Individual Disability, Long-Term Care or Health Insurance
Which of the following does your story involve?
Disability Long-Term Care Health
(1 story will be chosed from this category)
Workplace Benefits
Which of the following does your story involve?
Life Disability Long-Term Care
  Type of Coverage
Employer Paid Employee Paid
  (1 story will be chosed from this category)

2. To protect the client's privacy, please provide only first name, city and state.

 

 

 

3. Please indicate your client's race/ethnicity (optional):
African American/Black
Asian American
Asian, including Indian Subcontinent
Hispanic/Latino/Mexican American
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White/Caucasian
Other (please list below)

4. Year event took place

(only events that benefited clients from Jan 1st, 2000, or later are eligible)

5. Which of the following financial products did your client have?
Life
Health
Disability
Long-term care
Annuities
Other (please list below)

6. From which company(ies) was the policy(ies) that benefited your client purchased?

7. How long was the policy(ies) that benefited your client in effect?
years

8. Briefly describe how your client used the money from his/her policy(ies):

Yes No

10. How did you first learn about this year's realLIFEstories Client Service Award program?
Agency
Company
Email
Trade Publications
Local or state associations
Direct mail
Other (please list below)
Enter verefication code:   
Essay:
(In the form below, please write an essay of no more than 600 words describing your client's realLIFEstory. Entries will be judged primarily on the compelling nature of the stories and how well they demonstrate the role and value of life, health, disability, or long-term care insurance. Exceptional service on the part of the agent will also be an important criterion. If your story is chosen to be featured in Newsweek, it will be professionally rewritten prior to publication.
I certify that all information submitted is accurate to the best of my knowledge.