If you are a California resident who is shopping for a life insurance policy and want to receive a very competitive life insurance quote from my agency, please fill in as many fields of the following form as you are comfortable with. Once you have completed the form press the SEND FORM button located at the bottom of this page.

Once I receive your quote request I will e-mail your quote to you. The competitive quote you receive will reflect the fact that I represent some of the largest, highest rated, and most competitive life insurance companies in the United States.

Please send me an e-mail message if you have any questions or comments about this form.

Thank you for taking the time to visit.

Bill Baker, J.D.
Financial Consultant
Life Insurance Brokerage

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Please complete the following form and press the SEND FORM button when you are done.

Enter your first name:
.Enter your last name:
........Street Address:
...................City: State: Zip:

Spouse's First Name [Optional]:

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E-mail:

Phone (xxx-xxx-xxxx): Fax:

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Amount of Life Insurance Requested $ Age (nearest birthday):
Spouse's Age (nearest birthday) [Optional]:

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TYPE OF LIFE INSURANCE Proposal Requested:
TERM CASH VALUE BOTH

If Term Selected, Policy Term Requested:
[PULL DOWN MENU]
5 YEARS 10 YEARS 15 YEARS 20 YEARS

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LIFE INSURANCE Proposal Requested for:
YOURSELF YOURSELF & SPOUSE

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PULL DOWN MENUS

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Mode of Premium Payment Desired:
Monthly Quarterly Semi-Annually Annually

Health:
Excellent Very Good Good Fair Poor

Sex:
Male Female

Any Tobacco use in past 12 mos.?
NO YES

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Additional Comments

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Copyright © 1999 WM. BAKER ASSOCIATES
All Rights Reserved

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