Life Insurance
Quote:
We would like to provide
you with a free, no-obligation Life 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 fill out one form
per person in your family that is requesting an insurance
quote. 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 Coverage Information:
Company Name:
Face Value/Cash Value
Effective Date:
Annual Premium:
Person to be Insured's
Information:
Insured's Name (Last, First, M):
Date of Birth:
Relationship to Insured:
Sex:
Marital Status:
Occupation:
Weight:
lbs.
Height:
feet inches
Tobacco Products:
Health Condition:
Life Coverage Requesting or
Applying For:
Amount of Coverage:
Type of Coverage:
Disability Income:
Long Term Care:
Please indicate in the box below, any other information
you deem necessary, for us to give you the most accurate
quote possible.
Personal & Professional
Service
is what you will find at
Barkema
Insurance Agency..... Let us serve you today.
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 135th Ave (Murray cemetery) Turn
right (north) & go ¾ mile. When the road
curves to right, go left (1st ST).
We are about 1 ½ blocks down on the Left (north) side of
the street.
109 1ST St
