Hickok & Boardman, Inc. - Home PageDescription of homeowners, auto and life insurance products offered by our agency.Description of the insurance products we offer commercial clients.Description of unique insurance programs for specialized industries or individuals with high valued homes.Get a quote by filling out the applications available here.Frequently requested forms and summary of some of the services H&B offers.Provides our history and job opportunities.

Please fill in the following information and an agent will contact you within the next business day. If your request is for health insurance, please provide only contact information. You must reside in Vermont in order for us to provide you with a quote.

General Information:

Name

Address

City/State/Zip


Email Address

Work Phone

Home Phone

Date of Birth (mm/dd/yyyy)

Height/weight

Do you use tobacco?
Yes No

Month/year you last used:
cigarettes cigars chew pipe Nicotine patch

Medical Information:

Describe any pre-existing medical conditions, even if the condition has been resolved.


List any medication, including dosage and frequency.

Family Medical History:

Have your parents or siblings been diagnosed with:
Cancer? / Age diagnosis made:
Heart Disease? / Age diagnosis made:
High Blood Pressure? / Age diagnosis made:

 

Life Insurance Request:

Type of Insurance
Term      Permanent

Amount of Coverage:

(you may request multiple amounts)

Length of coverage for Term insurance:

(you may request multiple lengths of time, 10, 15, 20+ years)

 

Disabilty Income Insurance Request:

Occupation:


Describe job duties:


Gross Earnings (earnings before taxes)


Maximum monthly benefit requested:


Duration of benefits:
2-years 5-years to age 65

Waiting period before benefits begin:
60-days 90-days 180-days

 

Long Term Care Request:

Amount of Daily Benefit in a Nursing Facility:

(currently estimated at $170.00/day in Vermont)

Percent of Daily Benefit to be used for Home Care:
50% 75% 100%

Waiting period before benefits begin:
20-days 45-days 100-days

Duration of benefits:
2-years 3-years 4-years 5-years 7-years unlimited

Inflation Rider:
Yes No

Shared Care (Spousal) Rider:
Yes No

 

If you would like Spousal Coverage, please provide the following information on your spouse:

Date of Birth (mm/dd/yyyy)

Height/weight

Does your spouse use tobacco?
Yes No

Month/year you last used:
cigarettes cigars chew pipe Nicotine
patch

 

Medical Information:

Describe any pre-existing medical conditions, even if the condition has been resolved.


List any medication, including dosage and frequency.

 

Family Medical History:

Have your spouse's parents or siblings been diagnosed with:
Cancer? / Age diagnosis made:
Heart Disease? / Age diagnosis made:
High Blood Pressure? / Age diagnosis made:


 

Denis, Ricker & Brown, Inc. PO Box 565 Montpelier, VT 05601 | t/802-229-0563
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