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BGES Group
216 A Larchmont Acres W
Larchmont, NY 10538

"All Our Policies Come With
an Agent!"

On-Line Financial Planning Quotation Form One Simple Form - takes only 2-3 Minutes! *Your Personal Data*
Your Name:
Company Name (if applicable):
Street Address:
City:
State:
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Do You Own Your Own Business? Yes No

Do You Currently Have a Financial Plan? (If yes, list carrier, type of plan. If none, type N/C)

UNDERWRITING INFORMATION
(We ask health data in case financial plan funded by insurance)

Insured Name: Birthdate:

Insured Height: Insured Weight:

Insured Occupation: Hazardous Activities? (if yes, describe):

Sex (M/F): List children's
ages to be covered

Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!

Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)

Any Pre-existing Health Conditions?
(If yes, descibe in detail, and to which of the insured persons they apply.)

Any Covered Persons Currently Taking Medication of Any Kind?
(If yes, descibe in detail, and to which of the insured persons they apply.)

COVERAGE INFORMATION

Check the Kind(s) of Plans You Are considering:
Retirement Plan
401K Plan
IRA (Retirement) Plan
Annuity Savings Plan
Other Type of Pension Plan (describe in remarks)

How Much do Your have to Invest Monthly?
(so we may present to you the best investment options.)
$ per month.

Tell Us What Kind of Financial Planning You Need Help With. If You Are Looking for a Retirement or Pension Plan, 401K, or Annuity Plan, Tell Us What You Want Most in Your Plan, and List any other Remarks Here:

Send my quotation via: E-Mail Fax
Regular Mail
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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me Information
on Financial Planning Now!

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