(218) 628-6180 Duluth, MN

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Life Insurance Quote Form

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Insured Information

Name *

Date of Birth *

Gender
Male Female

Tobacco Use?
Yes No

Phone Number *

Email *

Street Address *

City *

State *

Zip *

Spouse Name

Date of Birth

Gender
Male Female

Tobacco Use?
Yes No

Child 1

Date of Birth *

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

Insured Name *

Address *

City *

State *

Zip *

Home Phone

Email *

Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Visit Our Locations in: Baxter Duluth Nisswa Wadena Alexandria MN.

Benes Insurance ~a Strong Company | 434-B North 57th Avenue West | Duluth, MN 55807 | (218) 628-6180

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