Life Insurance

ALEXANDER KASHI AGENCY

We are licensed in most states, and we offer a variety of products to fit your needs. In case you’re involved in an accident or a loss, our polices can help provide financial protection for you and your family.

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(310) 337-7459

7740 W. Manchester Ave Suite

[email protected]

LIFE

Name

Address

Telephone

Date of Birth

Social Security Number

Current Age

Current Height

Current Weight

Driver’s License #

Exp. date

Weight

Height

Health Condition

Any health issues

Do you Smoke

How often do you smoke

Do you drink

How often do you drink

Income / year

Employer information

Current medical provider – Doctors Name, Address, Tel number, Last visit

Any current life insurance policy you have or had, carrier Name, Date, Face amount, Type

Beneficiary – Name, Date of birth, Social Security number, Email, Telephone

Type of Life insurance required

Face Amount of coverage required $

Parents health condition (living or deceased), # of Siblings, health conditions

APPLICANT’S STATEMENT:
I HAVE READ THE ABOVE APPLICATION AND INFORMATION PROVIDED. I DECLARE THAT THE INFORMATION IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. THIS IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE PER MY OWN REQUEST A FREE NON-OBLIGATED QUOTE PROPOSAL FOR WHICH I AM APPLYING.

DISCLAIMER: PLEASE BE ADVISED THAT THIS WILL BE A FREE, NON-OBLIGATED ESTIMATED QUOTE PROPOSAL. THIS IS NOT A POLICY OF INSURANCE, A BINDER OR OFFER TO INSURE. THIS ESTIMATE WILL REFLECT RATES IN EFFECT AS OF THE DATE OF THIS ESTIMATE AND IS SUBJECT TO UNDERWRITING GUIDELINES, INCLUDING VERIFICATION OF INFORMATION PROVIDED AND AN INSPECTION, PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED IN CONNECTION WITH THIS ESTIMATED QUOTE PROPOSAL

If you are human, leave this field blank.

ALEXANDER KASHI AGENCY

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ALEX KASHI AGENCY, INC.

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