M.C.D. Financial Services
"Your Complete Satisfaction is our policy..."

Asthma
Questionnaire
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This was the easiest site to use and the results of our simple search really paid off. Thank you.
Mr and Mrs Harrison, Long Beach, CA

We used your service years back and the service we have received from you has continued to be very special. Thank you for all the help in continually guiding us to select the right plans for us.
D. Aldrich, Exeter RI

We really did not have time to meet with anyone. It was so refreshing to be able to work with some of your professionals who helped us entirely by phone and mail. Thank you!
Mr. & Mrs. Lipka, Boston MA

Your representative was extraordinary. Thanks again. We will definitely recommend your site.
J. Stahl, Dix Hills NY

We were so sure we had selected the right plan from all the quotes we'd received. We almost ended up wasting a lot of time and money. The selected representative took the time to explain all options available to us (even the ones we had received from other companies.) You have definitely earned our business.
The Morse Family, Plymouth CT

Thank you for all the help and the great service!!!
S. Harvey, Lebanon, NH

"You've cut my insurance premium in half!"
Katherine Havener
Toluca Lake, CA

"This site is a must for anyone shopping for competitive rates."
Susan White
Ft Myers, FL

"A godsend for those who are shopping around for the best deal in insurance."
Reinhard Tennyson
San Rafael, CA

"I just bought insurance using your site and saved $2,640 per year! "
Bob Jetter
Vancleave, MS

"I shopped from my own office and found the best deal available. "
Linda Picazio
Ft. Lauderdale, FL

". . . makes shopping for the cheapest insurance policy much easier. "
Parents in OH

This Questionnaire Will Help us Help You Find the Right Company at the Lowest Rates Possible

 
Amount of Coverage Needed
$
 
First Name
 
Last Name
 
Address
 
City
   State      Zip 
 
Phone (Day)
 
Phone (Evening)
 
e-mail Address
 
Smoker?
    If Yes, what?
 
Birthday
 xx/xx/xxxx
 
Gender
 
Height and Weight
Height: Feet    Inches            Weight:
Important Health Questions
In The Past Have You Been Declined For Insurance?
If Yes, Name of insurance company:
 Yes      No
Approximate Date Diagnosed with Asthma
xx-xx-xxxx

How Often Do You Have Asthma Attacks

How Severe Are Your Asthma Attacks (check one)?
Very Mild
Mild
Severe  
Very Severe
Medication(s) used:
 
Do You Use Steroids?
Yes     No

Have you Been Hospitalized?

Yes      No  
If you have any associated impairments, please list:
Please check Below which best describes your asthma history:
         I have not lost any time from work and I occasionally use an oral inhaler.
         If yes, check here
OR - I take no more than an occasional day off from work and use an oral inhaler and/or injections when necessary to break attack.
         If yes, check here
         How many days of work have you missed in past 12 months

OR - I have had episodes that required hospitalization. If yes check here   
         and How many times have you been hospitalized in the past 12 months?

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                                                            M.C.D. Financial Services    Pittsburgh, PA

 

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