Lake Agency

Call: 800.225.5960
810.694.2050

Life & Health Insurance Quote

Please fill out the sections below so we can contact you with your quote:

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Applicant(s) Information

* Address:

* City:

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Insured Information

	Yourself	Spouse
First Name
Last Name
Date of Birth
Gender	Male Female	Male Female
Height	ft in	ft in
Weight	lbs	lbs
Occupation
Covered by a Workers Compensation Program?	Yes No	Yes No

Number of Dependent Children:

Are you or your spouse pregnant?

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Requested Quote Information

What is the purpose of the new policy?

Desired Life Insurance Coverage:

Desired Health Insurance Deductible:

Desired Co-Pay:

Maximum Amount:

Optional Coverages:

Maternity Prescription Card Wellness

Covered Persons :

Brief Medical History:

How would you like to be contacted with your quote?

Telephone:

E-mail:

Fax:

Postal Address:

Send me a quote by U.S. Mail to the address given above.

After completing the above form, please click the Get A Quote button once. Thank you.