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Name:
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Home Phone #:	() -
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For coverage on yourself, compete this box:
Your birth date: , 19

Do you smoke? Yes No
If no, have you quit smoking in the last three years?: Yes No
Amount of life insurance coverage desired: $

Kind of life insurance desired: Term
Permanent or Cash Value
Don't know

Health Status:
Excellent (trim, athletic, no medications)
Good (no infirmity or medications)
Fair (taking medications or slightly overweight)
Poor (Describe problem below)

Describe any medical problems:

For coverage on your spouse complete this box:
Your spouse's birth date: , 19

Do your spouse smoke? Yes No
If no, has your spouse quit in the last three years?: Yes No
Amount of life insurance coverage desired: $

Kind of life insurance desired: Term
Permanent or Cash Value
Don't know

Health Status:
Excellent (trim, athletic, no medications)
Good (no infirmity or medications)
Fair (taking medications or slightly overweight)
Poor (Describe problem below)

Describe any medical problems:

Comments or questions:

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Life Insurance Home Page

The PGA Financial Co.
PGAFinancial.com
Call: (909) 790-8622
Toll Free (877) 336-5490

E-mail: Service@PGAFinancial.com
34455 Yucaipa Blvd.
Suite 209
Yucaipa, California
92399 Lee Martinson

Licensed in:
Arizona, California (license #0629626), Oregon, Texas, and Virginia. For other states, inquiries are referred 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.