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VALERIE FINANCIAL GROUP
Financial Freedom starts with a PLAN!
11
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1
Full Name
*
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First Name
Last Name
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2
Birthday
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Date
Year
Month
Day
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3
Height and Weight
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4
What type of coverage are you interested in?
Choose as many as you would like.
Income Protection
Burial/Final Expense Insurance
Life Insurance
Medicare Adv/Med Supp
Long Term Care
Health Insurance
Hospital Indemnity/Copay Protect
Index Universal Life (IUL)
Disability Insurance/Short/12+
Health Supplements
Income Protection
Retirement Planning
Tax Services
Children's Life
Small Business Planning
Car Insurance
Homeowners Insurance
Estate Planning
Policy Review
Notary Services
Legal Services
Stroke/Heart Attack/Cancer Policy
Unsure
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5
Phone Number
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6
E-mail
*
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7
Beneficiary
First Name
Last Name
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8
Do you have any medical conditions/diagnosis?
YES
NO
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9
Please list any medical conditions/diagnosis?
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10
List any medications that you are prescribed
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11
Please add any additional comments or questions:
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