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| Call Us Now For Instant Quote |
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| 1-800-566-8689 |
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| ARG & Associates will provide you with a free, no-obligation Home and Earthquake Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote. |
| 1st Insured/Primary |
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| Name: Date of Birth: Sex: Male Female |
| Marital Status: Married Single |
| Occupation: |
| Weight: Height: feet Inches |
| Health History |
| Have you had any of the health condition listed below? If you answer yes please explain below: |
| Heart disease? Yes No |
| Cancer? Yes No |
| Diabetes? Yes No |
| High Blood Pressure? Yes No |
| Frequent hospital visits? Yes No |
If you answered Yes to any of the questions above please explain in the space provided below:
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| Tobacco Products |
| Have you ever used any tobacco products? Yes No, if yes, please answer the questions below: |
Have you quit using tobacco products? Yes No, if yes,
how long ago did you quit? And,
how many years did you use tobacco products? And,
how many packs did you use per day? |
| Are you currently using Tobacco products? Yes No, if yes, please answer below: |
What type of tobacco products are you using? Cigarette Cigar Pipe Smokeless
Other: |
| How long have you been using tobacco products? |
| Current Insurance Information |
| Do you currently have health insurance coverage? Yes No, if yes, please answer the information below: |
| Carriers Name: |
| Policy Number: Policy Expiration Date: |
| Premium Amount: $ |
Please indicate whether the premium is: Monthly Quarterly Bi-Annual Annual
Other: |
Please list the amount/s of life insurance you would like quoted: $100K $250K $500K $1mil.
Over |
| Additional Details |
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Please list below any additional details about your health or anyone else to be insured in the space provided below:
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| When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly. |