Flagship Insurance & Financial Services, Inc., Winsted, Minn.

Life Insurance Quote Fax Form

Please print this form, fill in the information, and fax it to
(320) 485-2199

Name	_______________________________________________________
Phone number with area code	_______________________________________________________
Best time to call	_______________________________________________________
Date of Birth	_______________________________________________________
Amount of Coverage	_______________________________________________________
Smoker?	Yes_______ No_______
Type of Policy	Term_______ Universal Life________ Whole Life_______

Thank You!
We will contact you soon!