DENTAL INSURANCE QUOTE (Customized and personalized)
APPLICANT ALL INFORMATION IS CONFIDENTIAL SPOUSE 
CHILDREN
CHILDREN First Name: First Name: Number:
Last Name: Gender:
Telephone Number (Including area code):
Email Address:
INSURANCE
ANNUITIES
RETIREMENT INCOME
EMPLOYEE BENEFIT PLANS
WEALTH PRESERVATION
BUSINESS PLANNING
TAX AVOIDANCE STRATEGIES
Is current coverage through an Employer Plan?
Do you currently have a Dentist you don't want to lose? .
List any current dental issues below !
Type of Plan:
Resident City:
Currently on Medicare:
Transitioning to:
Resident State:
Resident Zip Code:
I'M ALSO READY TO TAKE ACTION ON:
Are you self-employed?
Gender:
Smoker:
Age:
Currently on Medicare:
Transitioning to:
Do You Currently Have Dental Insurance?
If YES, What Company?
If YES, Full Name:
Phone Number:
Age:
Are you self-employed?
Do you have health insurance:
I was referred by:
Michael Mendonca, FLMI
Covered California
Certified Insurance Agent
Insurance
Annuities
Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource
949.954.4445
