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Record Request Order Form

Customer information:

* Required Fields

 * Customer / Firm Name:

Date:
 Address1: * Phone: 

 Address2:

Fax:
 Contact Person: Direct Dial: Email:
 Assistant/Secretary: Direct Dial: Email:
 Billing Address(if different): 
Type of Order:
Single Orders
Order Verification of Coverage: $30.00 Yes No (Click here to view our VOC form)
Order In-force Illustration Request: $30.00 Yes No
* illustrations will be ran to policy maturity, with minimum level premiums and level death benefit unless otherwise specified.
Order Summary of Significant Medical Factors: $75.00 Yes No
Order Life Expectancy Reports: $10.00 Yes No We can request on your behalf;
AVS 21st Services EMSI ISC Services Fasano Associates GLU (Global Life Underwriters)
 
Discount Combo Orders
In-force Illustration Request & Verification of Coverage: $50.00 Yes
Medical Record Request from (2) Doctors: $55.00 Yes *plus any fees from doctors.
Medical Record Request from (2) Doctors &
Summary of Significant Medical Factors: $130.00 Yes *plus any fees from doctors.
 
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In-Force Illustration
Verification of Coverage
Medical Records from (2) Doctors
Summary of Significant Medical Factors
Order (2) Life Expectancies Reports $195.00 Yes *plus any fees from doctors.

Each additional Doctor $25.00 *plus any fees from doctors..
 

Insurance Information Request:

* Name of Insured:   AKA:  

Carrier: Policy Number:

Name of Policy Owner:
SSN#: * DOB: DOD:
 Address1:
Address2:


Click Here to download policy release form
Click Here to attach and email your policy release form

 
 
Medical Records
Records Pertain to : DOB SS#  
Doctor's Name : Phone:    
Doctor's Address :
Medical Records Chart: Billing Records Full Chart Abstract
Specific dates of records from: to:
Click here to attach and email a medical release (HIPAA) form
To Add Additional Doctors Click Here: new section will show at the bottom of this page to add new doctors
 
Special Instructions (Specific):
 


 

Other Instructions (General)

* Please Fax Authorizations to: (513) 685-7330 or Email to: info@recordexpressllc.com

Select the method you will use to send authorizations:
Email