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Kopec Flagler County Chamber

Flagler County’s Preferred Insurance Agency

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Life Insurance Quote

Business Name:
Work Phone:
Home Phone:
Cell Phone:
How Did You Hear
About Us?:
Referral (please specify)
Internet (please specify)
Community First Yellow Pages (employee group photo on
      cover, glossy pages)
Flagler Chamber of Commerce Phonebook (scenic
      beach/dolphin photo cover)
Yellow Book Phonebook- Flagler County Directory &
      Shopping Guide (yellow cover)
AT&T (Bellsouth) Phonebook
Other (please specify)
Are you a smoker? Yes   No
Please indicate any history of health problems:
Please indicate any history of health problems for your father and mother:
Has any immediate family member passed away before age 60 as a result of cardiovascular problems or cancer?
Yes   No
Desired Benefit Amount:
Are you interested in term or permanent life insurance?
Term   Permanent
Prior/Current Carrier:
Current premium amount per month:
Current policy expiration date:

Don't forget to have our office review your entire insurance portfolio
including auto, home, marine, life, and business insurance.

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