DeLand (386) 734-0800
Edgewater (386) 427-5201

Locations & Hours   Contact Us

OUR BUSINESS IS PEOPLE, NOT POLICIES

We strive to provide affordable, comprehensive coverage and look forward to building a long-term relationship with our clients.

There's no business exactly like yours; so you can't afford to waste money on one size fits all insurance.

We offer health & disability coverage for all your insurance needs.

Individual Health Quote
Date

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Lead Score

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Client Name

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Date of Birth

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Tobacco Smoker

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Height/Weight

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Preferred Effective Date

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Address

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Phone

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Email

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Current Insurance Information

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Include a spouse and/or children? Please provide necessary info below:
Spouse Name

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Spouse Date of Birth

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Spouse Height/Weight

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Tobacco Smoker

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Childrens Gender

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Childrens date of birth

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Important Physicians?

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Medications?

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Comments

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Please note:Policies are subject to medical underwriting. All information provided on this form is strictly confidential.


Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

Our Carriers

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