(209) 826-9500 Los Banos, CA

EFR Insurance Agency

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Insured Information

Name *

Date of Birth *

Gender
Male Female

Tobacco Use?
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Phone Number *

Email *

Street Address *

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Spouse Name

Date of Birth

Gender
Male Female

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Child 1

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Gender
Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
Male Female

Amount of Death Benefit

Insured Information

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Use Tobacco
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Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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EFR Insurance Agency | 864 5th Street | Los Banos, CA 93635 | (209) 826-9500

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