LIFE INSURANCE QUOTE (Customized and personalized)
APPLICANT SPOUSE CHILDREN
First Name: First Name: Ages:
Last Name: Gender: Smoker:
Telephone Number (Including area code):
Email Address:
Resident State: Ex.(CA, AZ, etc.)
Gender: Smoker:
Amount: Monthly Premium Budget:
Currently Insured: What company? What Type of Policy:
INSURANCE & ANNUITIES
INCOME PLANNING
EMPLOYEE BENEFIT PLANS
BUSINESS PLANNING
I'M ALSO READY TO TAKE ACTION ON:
List prescription medications and what health issues they address for all the above. Also use below area for any notes. notes!
ALL INFORMATION PROVIDED IS CONFIDENTIAL !
I was referred by:
Height:
Weight:
Type of Policy:
Height:
Weight:
Type of Policy:
Amount:
Monthly Premium Budget:
I'm purchasing life insurance for the following reason:
Date of Birth: Ex.(01/01/2000)
Date of Birth:
Michael Mendonca, FLMI
Covered California
Certified Insurance Agent
Insurance
Annuities
Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource
949.954.4445
