(760) 409-4477
Palm Desert, CA
Medicare Open Enrollment - October 15 - December 7th
Sandra Barr Insurance Services
Medicare Open Enrollment - October 15 - December 7th
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Gender
Male
Female
Tobacco Use?
Yes
No
Child 1
Date of Birth
*
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Gender
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Child 2
Date of Birth
*
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Gender
Male
Female
Child 3
Date of Birth
*
Jan
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Apr
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1
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Gender
Male
Female
Amount of Death Benefit
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1,000,000+
Insured Information
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Address
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City
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State
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Zip
*
Home Phone
Email
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Use Tobacco
Yes
No
Gender
Male
Female
Date of Birth
Height
Weight
List medications and reasons
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