James B. Kelly & Associates, Seaside, Oregon

&
Associates

Insurance
P.O. Box 473
Seaside, OR 97138
(503)738-5417 Fax: (503)738-3597
e-Mail: kellyinc@pacifier.com

We Specialize in Individual or Company Group Insurance
Employee Benefit Plans.
May We Furnish Proposals for Your Consideration?

James B. Kelly and Associates has been in our profession for over 36 years. We are licensed in Oregon and Washington and are affiliated with over 30 leading insurance companies. James B. Kelly and Associates furnishes proposals and services to individuals and companies on a NO-COST OR OBLIGATION basis. All we ask is you do business with us when we have the best proposals and suggestions for your review.

Print this page. Then, please mark the programs below that interest you. Complete the form according to your needs and fax or mail it to us. We will select the best insurance plans according to your needs and prepare proposals from several companies for you. We will forward the results to you as soon as possible.

INDIVIDUAL PLANS				COMPANY PLANS 1 OR MORE PERSONS
__	Medical	__	Short Term Medical	__	Group Medical	__	Retirement Plans
__	Disability Income	__	IRA	__	Group Life	__	Disability Income
__	Annuities	__	Vision	__	Group Vision	__	Voluntary Plans
__	Term Life	__	Dental	__	Group Dental	__	Buy & Sell Plans
__	Long Term Care	__	Medicare Plans	__	Group Chiro.	__	Long Term Care
__	Spouse Insurance	__	Children's Insurance	__	Group Nat.	__	Key Person Plans
__	Immediate Annuities	__	Other:	__	Special Interests:

INFORMATION NEEDED TO PREPARE FIRM PROPOSAL
Name: ______________________ Phone: __________	Company Name: ______________________________
City: ______________________ St: __ Zip: ________	City: ______________________ St: __ Zip: ________
Occupation - Husband: __________ Wife: __________	Type of Business: ____________________________
Person to Call For More Info.: ____________________	Contact Person: ______________________________
Phone No.:________________Fax: _______________	Phone No.:________________Fax: _______________
Personal Information:	Employee Information
Primary Name: ___________M/F Age ___ Smoker? ___	Age/Sex/Spouse Age/#Children/Job Title/Weekly Income
Spouse Name: ___________M/F Age ___ Smoker? ___
Children Ages: _______________________________
Annual Income: (Disability income plans only)
Primary: $_____________ Spouse: $_____________	(Use back of sheet or attach list is more employees.)
Present Health Insurance Carrier? _________________	Present Health Insurance Carrier? __________________
Please list any special benefits you would like to have.	Please list any special benefits you would like to have.
___________________________________________	____________________________________________
The information you provide will be considered to be confidential and will only be used to obtain proposals from insurance companies. It may take about a week to obtain proposals. If you have any questions, please call. We are looking forward to be of service to you.