PG Paramedical Examiners
Our reason for existing... you!
Company Info
Our Services
Order Exam
Medical Education
Contact US
Fill out the form:
Importante todos los campos de esta forma deben ser llenados, para poder enviarla sin errores. Si algún campo no aplica puede poner N/A o no aplica.
Insurance Company Name:
*
AETNA LIFE INSURANCE COMPANY
AFLAC
AID ASSOCIATION FOR LUTHERANS
AIG LIFE INS. CO. OF PR
AIG LIFE INSURANCE CO.
ALEXANDER HAMILTON LIFE INS CO.
ALL AMERICAN LIFE INS. CO.
ALLIANZ LIFE INSURANCE COMPANY
ALLIED LIFE INSURANCE COMPANY
ALLMERICA FINANCIAL
ALLSTATE LIFE INSURANCE
AMERICAN GENERAL LIFE PARA-UW
AMERICAN GENERAL LIFE & ACCIDE
AMERICAN GENERAL LIFE INS. CO.
AMERICAN INS. CO. OF TX
AMERICAN INTERNATIONAL LIFE IN
AMERICAN MAYFLOWER LIFE INS. C
AMERICAN NATIONAL
AMERICAN STATES LIFE INSURANCE
AMERICO FINANCIAL
AMERUS LIFE
ATLANTIC SOUTHERN INSURANCE COMPANY
AXA EQUITABLE LIFE INSURANCE
BANNER LIFE INS. CO. OF NEW YORK
BANNER LIFE INSURANCE COMPANY
BENEFICIAL LIFE INS CO
BERKSHIRE LIFE INSURANCE CO
BMA (GENELCO)
BOSTON MUTUAL
BUSINESS MEN'S ASSURANCE
CANADA LIFE INS. CO. OF NEW YORK
CANADA LIFE INSURANCE COMPANY
CHUBB LIFE INS. CO. OF AMERICA
CNA INSURANCE COMPANY
CONNECTICUT GENERAL LIFE INS CO
CONSECO LIFE (EMPLOYEE PROG.)
CONSECO MEDICAL - HEALTH
CONTINENTAL GENERAL INS. CO.
COSVI
COSVI SEGURO GRUPAL
CUNA MUTUAL LIFE ASSURANCE
EMPIRE GENERAL LIFE ASSURANCE
FAMILY FINANCIAL LIFE INS CO
FAMILY LIFE INSURANCE
FEDERAL KEMPER LIFE ASSUR. CO.
FIDELITY & GUARANTEE LIFE INS
FIRST COLONY LIFE INSURANCE CO
FIRST PENN-PACIFIC LIFE INS C
FORTIS / HEALTH INS CO
FRANKLYN LIFE INSURANCE COMPANY
FREEDOM LIFE INSURANCE CO
GENERAL AMERICAN LIFE INS. CO.
GLEANER LIFE INSURANCE
GOLDEN RULE INSURANCE CO.
GPM (SAN ANTONIO)
GPM (TERM/INDY)
GUARANTEE LIFE / WESTFIELD
GUARANTEE TRUST LIFE
GUARDIAN LIFE INSURANCE COMPANY
HARTFORD LIFE
INDIANAPOLIS LIFE INSURANCE CO
INTERSTATE ASSURANCE CO.
INVESTORS LIFE INSURANCE CO.
INVESTORS LIFE OF INDIANA
INVESTORS LIFE OF N.A.
INVESTORS PARTNER LIFE
JACKSON NATIONAL LIFE INS. CO.
JEFFERSON PILOT LIFE INS. CO.
JOHN ALDEN / BOISE INS CO
JOHN ALDEN / BOSTON INS CO
JOHN ALDEN / DUBLIN INS CO
JOHN ALDEN / PLYMOUTH INS CO
JOHN HANCOCK MUTUAL LIFE INS CO
KNIGHTS OF COLUMBUS
LAFAYETTE LIFE INS CO
LIFE INVESTORS INS CO
LIFE OF VIRGINIA
LIFE USA
LINCOLN BENEFIT LIFE COMPANY
LINCOLN LIFE OF CONNECTICUT
LINCOLN SECURITY LIFE INS CO
MAGNA INSURANCE COMPANY
MANHATTAN LIFE INSURANCE CO
MANHATTAN NATIONAL LIFE INS CO
MANULIFE FINANCIAL
MASS INDEMNITY
MASS MUTUAL
MASSACHUSETTS GENERAL LIFE INS
MERRIL LYNCH VAR. LIFE SERV CO
METROPOLITAN LIFE
MIDLAND LIFE INSURANCE CO.
MIDLAND NATIONAL LIFE INS CO
MINNESOTA MUTUAL LIFE INS CO
MONUMENTAL LIFE
MONY LIFE INSURANCE COMPANY
MULTINATIONAL LIFE
MUTUAL OF OMAHA
N. AMER. CO. FOR LIFE & HEALTH
NATIONAL BENEFIT LIFE
NATIONAL BENEFIT LIFE/CITIBANK
NATIONAL FOUNDATION LIFE
NATIONAL LIFE INSURANCE
NATIONWIDE LIFE - AGENCY
NATIONWIDE LIFE - BROKERAGE
NATIONWIDE LIFE - GROUP
NATIONWIDE LIFE - HEALTH
NATIONAL WESTERN
NEW ENGLAND
NEW YORK LIFE INSURANCE COMPANY
NORTHWESTERN MUTUAL
OHIO NATIONAL LIFE INS CO
OLD LINE LIFE - VALIC
OLD LINE LIFE - INSURANCE CO
OLD REPUBLIC LIFE INSURANCE CO
PACIFIC LIFE
PAN AMERICAN
PAN AMERICAN ASSUR
PAUL REVERE LIFE INS. CO.
PENN MUTUAL LIFE INS CO
PHILADELPHIA LIFE INS. CO.
PHOENIX HOME LIFE MUTUAL INS CO
PRAICO
PRIMERICA LIFE
PRIMERICA LIFE/CITIBANK
PRICIPAL MUTUAL LIFE INS CO
PROTECTIVE LIFE INSURANCE CO.
PROVIDENT LIFE ACCIDENT INS.
PROVIDENT LIFE & CASUALTY INS.
PROVIDENT LIFE INSURANCE COMPANY
PROVIDENT MUTUAL LIFE INS CO
SBLI USA MUTUAL LIFE INS. CO
SECURITY CONNECTICUT LIFE INSURANCE
SECURITY FIN LIFE/WORKSITE MKT
SECURITY LIFE OF DENVER
SOUTHLAND LIFE INS. CO.
STARMOUNT LIFE INS. CO.
SUN LIFE ASSURANCE OF CANADA
SUN LIFE OF CANADA GROUP
TOLIC
TRANSAMERICA OCCIDENTAL LIFE
TRAVELERS LIFE
TRIPLE S VIDA - SAN JUAN
UNITED OF OMAHA
UNITED SERVICES LIFE INS CO
UNITED STATES LIFE INS CO
UNIVERSAL GUARANTY LIFE INS CO
UNIVERSAL LIFE INS
US FINANCIAL LIFE
USA MUTUAL LIFE INS
VALLEY FORGE LIFE INS CO
WEST COAST LIFE INSURANCE CO.
WESTERN RESERVE LIFE
WESTFIELD LIFE
WILLIAM PENN LIFE INS CO OF NY
WORLD INSURANCE CO.
ZURICH LIFE INS CO OF AMERICA
Policy Number:
*
First & Last Names:
*
Last 4 Digits of SS:
*
Date of Birth:
*
Amount of Coverage:
*
Home Address Information
Address:
*
City:
*
State:
*
Zip Code:
*
Home Phone:
*
Type of Exams
Type of Exams:
*
Paramedical Exam
Full Blood
EKG
Urine
Measurement on Lab Slip
Physician Exam
Short Form
Mini Blood
Finger Stick
Urine HIV
Repeat:
*
N/A
Yes
No
Other:
*
Special Requirement:
*
Agent/Agency Information
Agent's Name:
*
Agent's Phone:
*
Requestor Name:
*
Agent/Agency Code:
*
Agency Name:
*
Agency Phone:
*
Agent E-mail:
*
Confirm E-mail:
*
Comments:
*
Security
*