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 Life Quote
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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Amount of Protection

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Home Address

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Phone

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City/State/Zip

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Best time to call

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Spouse Name

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Spouse Height/Weight

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Spouse Date of Birth

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Spouse Amount of protection

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Tobacco Smoker

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Children Names Children DOB Gender


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Medications for client?

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Medications for spouse?

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Medications for children?

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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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