Laura Harris Agency Inc.
Professional Service
 
5350 S Staples St Suite 150
Corpus Christi, TX 78411
361-985-2875
361-985-0509 (fax)
email:dawneperez@allstate.com

Our agency is licensed to quote and write insurance policies only in Texas. To find agents offering these coverages in all other states, please click the IQ.net logo.

 

Life Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.
   
 Amount of Coverage to be Quoted  
 What type of life insurance policy are you interested ?  If Term, How many years?

 Name (required)  
 email Address (required)  
 Street  
 County  
 City, State, Zip  
 Daytime Phone  
 Night Phone  
 FAX  


 Personal Information
 Sex (required)  
 Date of Birth (required)  
 Height  
 Weight  
 Do you smoke cigarettes (required)  
 How much life insurance do you currently carry?  

 Have you ever had any indication of the following medical problems?
 
 Heart disease  
 Cancer  
 HIV  
 Diabetes  
 Cholesterol  
 High Blood Pressure  
 

 Please explain 'Yes' answers above and any medical problems you have had in the last 10 years:
 
 

If interested in a spouse, 2nd to Die or children's riders please give the following information
 

 Spouse

 
 Sex (required)  
 Date of Birth (required)  
 Amount of coverage desired  

 


 Children

 
 Amount of coverage desired  
 

 


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Page Created 4-29-02
 
 
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