Second to Die Quote

Complete this form to receive a quote for a
second to die policy.

Name:
Home phone #:	()-
Work phone #:	()- Ext
Best time and place to call:
Email address:
City:
State:
Your age:
Birthdate:	, 19
Sex:	Male Female
Do you smoke?	Yes No
Have you quit smoking in the last three years?	Yes No
Health Status:	Excellent (trim, athletic, no medications) Good (no infirmity or medications) Fair (taking medications or slightly overweight) Poor (Describe problem below)

For the second insured:
Name:
Age:
Birthdate:	, 19
Sex:	Male Female
Smoker?	Yes No
Quit smoking in the last three years?	Yes No
Health Status:	Excellent (trim, athletic, no medications) Good (no infirmity or medications) Fair (taking medications or slightly overweight) Poor (Describe problem below)

Amount of life insurance needed:	$ Don't know
Comments, or any other information that will help us get an accurate quote for you:
Check here if you are also interested in information on annuities

The PGA Financial Co.
PGAFinancial.com
Call: (714) 897-0955
Toll-free: (877)336-5490
E-mail: Service@PGAFinancial.com
13736 Goldenwest Street,
Suite H
Westminster, CA 92683
Lee Martinson

Licensed in:
Arizona, California, Oregon, Texas, and Virginia. For other states, inquiries are referred on to agents licensed to handle insurance in that particular state.

PGA Financial has no intent to generate interest in any particular life insurance company or specific policy, but rather to inform and educate you on the general concept -- after which, if you are interested, a broker at PGA Financial will be glad to research companies that offer such plans, get you a quote and assist you in making a choice. If you do become interested and obtain a policy, the broker would be compensated by the insurance company.

Complete this form to receive a quote for asecond to die policy.

Complete this form to receive a quote for a
second to die policy.