(281) 240-1166 Stafford, TX

Michael D. McKay Insurance Agency

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Insured Information

Name *

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Gender
Male Female

Tobacco Use?
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Phone Number *

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Child 1

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Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
Male Female

Amount of Death Benefit

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Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Michael D. McKay Insurance Agency | 12603 Southwest Frwy, Suite 240 | Stafford, TX 77477 | (281) 240-1166

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