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Life Insurance Quote Form

Life Insurance Quote Form

Complete this HIPPA protected form to request a quote on your life insurance options. As a broker, Melissa will shop the best plans and put together the package that works best for your specific situation! 

HIPAA

Compliance

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    It's ok to be unsure! We can do a needs analysis/calculation. Most people choose tend to fall into one of these brackets of coverage: $100,000-$500,000, $500,000-$1,000,0000 or $1,000,000 to $2,000,000. There are people who need more than $2,000,000 of coverage. Everyone's situation is unique. It's also possible to purchase more than one policy for different needs.
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    Choose all that you would like to see quotes for!
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    Life insurance goes by the state you are physically located in at the time of application. If you will be moving by the time you are buying a policy, please enter the new state. Right now, we are just doing price comparisons.
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    For example: US Citizen, Permanent Resident, Visa Holder, etc...
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    Life insurance companies use this to determine eligibility for coverage requested.
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    List your title and a brief description of your job duties.
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    Reviewing your current coverage helps me offer the best advice to you based on any existing coverage privileges you may/may not have in your policy. I don't need to see the price of your policy if you have the policy contract that is more appropriate for me to review.
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    Max. file size: 10.6MB
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    Please call Melissa Schreur directly if you are in need of immediate assistance (305)373-3666.
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