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To request more
information and get a Quote, please complete the form below.
Please know that all information is kept confidential and is
not shared with anyone except with Insurance Carriers &
Brokerage Firms for the purpose of obtaining proper quotes. It
is important to complete as much information as possible in
order to help you. Rates quoted are based upon the information
you provide. Below is a "Comment" section where you can
provide me with your health history, if any, that will help
with obtaining the most accurate quote possible. Final
rates and acceptance are always decided by the Underwriters of
any given Insurance Carrier. |
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Bold fields are
required |
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First Name |
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Last Name |
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DOB Month |
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Day |
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Year |
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Gender |
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Tobacco Products |
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Height |
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Weight |
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Occupation |
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Annual Income ONLY if Disability Quote
needed |
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Street Address |
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City |
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State |
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Zip Code |
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Email: |
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Optional Work Phone # |
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Extension |
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Optional Home Phone # |
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Preferred method for us to contact
You |
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Spouse Name (If to be covered)? |
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Spouse Gender? |
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Spouse Tobacco Products? |
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Spouse DOB Month? |
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Day? |
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Year? |
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Height? |
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Weight? |
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Children Coverage? |
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How Many? |
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List Gender and Age for each M= Male / F=
Female |
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All Term Life plans quoted and if Health quote
requested, all Deductables are quoted. |
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Type of Insurance to be
Quoted |
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To determine how much is right for you, read my
comments in the "Understanding Insurance"
section. |
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Amount of Life Insurance |
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Annuity or IRA Deposit |
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Frequency of Payments |
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Monthly Disability Amount |
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Please list any medications you and or any
family members being covered are taking, if any, and include
the dosage, frequency and the condition which they are for.
Please also list the date (month/year) of your last
physical.
Also if you want a quote on more than just one
product, please indicate so in the comment
section.
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Comments |
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Walter Diaz
8730 N. Himes Ave. # 815
Tampa, Florida 33614
813-915-9376
9:00 AM - 6 PM, Monday - Friday (Eastern
Standard Time)
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