Health Quote


Health Quote

Health Insurance Quote:

We would like to provide you with a free, no-obligation Health Insurance Quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. Please note this is not an application but a request for a quote and is non binding until money is received and we have accepted your application and we have completed the underwriting process.

Personal Information:

Name:

Address:

City:

State:

Zip:

Phone:

Email Address:

Current Health Insurance Information:

Company Name:

Expiration Date:

Effective Date:

Deductible:

Annual Premium:

Information:

Insured's Name (Last, First, M):

Date of Birth:

Relationship:

Sex:

Marital Status:

Occupation:

Weight:

lbs.

Height:

feet inches

Tobacco Products:

Health Condition:

The following may also be available to you:

If interested in any of these below, Click all that apply;

	Accident Rider	Chiropractor
	Dental Coverage	Request High Deductible
	Maternity Coverage	Mental Health Coverage
	No Deductible Co-Payments	Prescription Drug Card
	Preventative Coverage	Vision Care Coverage
	Wellness Coverage	Other (Please Describe Below)
	Deductible Request
Please indicate in the box below, any other information you deem necessary for us to give you the most accurate quote possible. Be sure to let us know what deductible you'd be interested in (above) as well. If no choice is made or none listed below in your comments, we will quote the same as you listed in the current coverage above.

Personal & Professional Service
is what you will find at
Barkema
Insurance Agency..... Let us serve you today.

Contact Us:
Phone
641-447-2544
1-877-INS-N-IA2
1-877-467-6422

EMAIL: barkema@grm.net

Mailing Address:
PO BOX 183
Murray, IA 50174 Physical Address:
109 1st St.
Murray, IA

Directions to our
Office:
From Osceola:
West on Hwy 34
9 miles From Creston East on Hwy 34
25 miles To 135^th Ave (Murray cemetery) Turn right (north) & go ¾ mile. When the road curves to right, go left (1^st ST).
We are about 1 ½ blocks down on the Left (north) side of the street.
109 1^ST St


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