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Contact Information
First Name:: *
Last Name:: *
Email:: *
State: *
Preferred Contact Number: *
Preferred Time To Call: *
Birth Date: *
Gender: * Male
Female
Have you used tobacco products in the last 12 months?: * No
Yes*
Do You Take Prescription Medication?: * No
Yes*
In the last 5 years, have you been hospitalized or had surgery?: * No
Yes*
Are you employed full time (at least 30 hours): * Yes
No
Annual Income: *
Please describe your duties:
Where is your office located?: * Home
Outside
Both
Are you disabled or receiving disability payments?: * No
Yes*
Are you currently covered by disability insurance?: * No
Yes
Are you requesting new coverage, replace coverage, or add to coverage?: *
What Amount of Monthly Coverage are you Seeking?: *
What Amount of Monthly Coverage are you Seeking?:
Please give details for any yes* answers:
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Atlantic Funding Group, Inc - 13575 58th St N. Suite 116 - Clearwater, FL 33760
Office Phone: 727- 738-8331 Fax: 727-738-1698 Toll Free Phone: 866-571-4759


Atlantic Funding Group, Inc. 

af logo
                                                                                                                            

           

An independent insurance agent.

Representing Capital Choice Financial Services a network of independent business men and women representing various life and health insurance companies.

 

 





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