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Every (26) Seconds, An
Accident
Happens…
To See If You *Qualify For A Plan To Offset Your Financial
Trauma
,
In The Event Of A Catastrophic Catastrophe,
At Virtually No Cost To You,
For Less Than .34¢ An Hour…
Please Complete The Following
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First Name
*
Last Name
*
Date Of Birth
Cell Phone
*
Address
Email
*
A. If You Were In A Coma, As A Result Of A *Catastrophic *Accidental Brain Injury, In Over The Last 12-18 Months, When You Came Out, What Would Your Life Look Like?
Email Result That
B. For Less Than .34¢ An Hour, In The Event Of A *Catastrophic Accident .. If You *Qualified For a Hardship Recovery Checkbook...At Virtually No Cost To You, Providing That You *Qualify, Would You Take Advantage Of It?
Yes
No
C. If You Were Confined To A Hospital, As A Result Of A Catastrophic Accident, Would You Want To Get Paid Per Day Or Remain Void Of Income, While Confined In The Hospital?
Get Paid Per Day
Remain Void Of Income
D. How Many "I HATE TO INFORM YOU" Checks.. Will *Life Write Today?
*Answer;
EVERY 2 SECONDS, *WE DON'T KNOW!
E. In The Event Of A *Catastrophic Accident, If You Could Use Our Money, Oppose To Using Your Money, To Offset Your Financial Hardship, As A Result Of A Catastrophic Accident, At Virtually No Cost To You, Providing That You Qualify, Would You Take Advantage Of It?
Yes
No
F. In The Event Of A Catastrophic Accident, How Long Could You Wait For Compensation/ Proceeds?
3 to 5 Years?
Or 30 Days?
.
IN THE EVENT OF A CATASTROPHIC ACCIDENT OR CRITICAL ILLNESS, TO ASSIST US
IN YOUR
QUALIFYING
, PLEASE TELL US, WHO WOULD SPEAK ON YOUR BEHALF WHEN YOU'RE NOT ABLE TO SPEAK FOR YOURSELF?
Emergency Contact
First Name
*
Last Name
*
Relation To Patient
*
Phone
*
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