Special
Insurance Quote Request
We provide you with a free, no-obligation  insurance quote.   Any comments regarding your personal health history will be kept in complete confidence and used solely to provide  the most accurate quote possible for you.  All  information is kept confidential and will not be used or resold for any purpose. Questions... call 1-888-456-1858
1-888-456-1858   (504)-456-1858  .......................... located in the "Big Easy", in New Orleans, La.
Please fill out the form below for quote requests.   (E-mail address and phone number are required entries.)

Please call or send me more information about:


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-----Major Medical Insurance----
International Major Medical Health
Excess Major Medical Health Insurance
Medicare Bridge Plan
Group International Major Medical Insurance

 -----Non Sports Disability Insurance Plans-----
Physicians & Surgeons High Limit Disability Insurance
Executive Plan Disability Insurance
Entertainment & Star Disability Insurance
Disability Insurance for personal or business needs
Pilots Disability Insurance

------Sports Disability Insurance Plans----
Professional Athlete High Limit Disability Insurance
Professional Racer Disability Insurance
Professional Golfers Disability Insurance
Pro Jockey  Disability Insurance
 


-----Life Insurance----
High Limit Accident Insurance
Confidential Insurable Interest  Life Insurance
International Term Life Insurancel

-------Contingency Programs----
Kidnap & Ransom Coverages
Event Cancellation/Non Appearance

-----Liability Insurance Plans----
Professional Athletes Asset Protector
Employment Practices Protector
Fixed or Equity Index Annuities

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----Buy-Sell Stock Redemption Plans---
Stock Redemption /Buy-Sell Life Insurance
Stock Redemption /Buy-Sell Disability Cover
Key Man/Executive Life Insurance
Key Man/Executive Disability Insurance
 

  I live in                          and my favorite hobby is:    
 

Myself:         Age:

Male/Female

Tobacco?

 

Spouse:       Age:

Male/Female

Tobacco?

Unmarried Dependents:  ----------> How Many?       Ages

Office Phone:  Fax:
Home Phone:   Cel:

Area Code         
Country Code
 

Your Name:
Occupation:

Street Address:

 email address: Required to contact you

City,St,Zip: 

Parish or County
Best Time to Call
Health Status:---------------------------------->       
Health conditions?
Yes No      ------------------------------->
Please Explain: give details of health status:
Prescription medications?
Yes No     -------------------------------->
Explain: (mgs?)  (xdaily)
Do you engage in any hazardous activities?
(i.e. scuba,skydiving,private pilot,etc.)
Yes No
Explain:
Current Insurance Company and benefits                                    

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