Benefits Consultants

Tim B. Piatchek, LUTCF, LC

Serving the Ozarks and

Southwest Missouri

since 1968!

Call us locally at 417-877-1567 or Toll-Free at 866-716-4555

HOME

 Meet Tim Services Contact Us Testimonials

MEET TIM!

 

Individual Health Plan

 

Group Health Plan

 

Term Life Insurance

 

IRA - Annuities - 401K Rollover - Retirement Planning

 

 

 

 

 

 

 

   Term Life Insurance

The quote you are requesting requires that you complete the following survey as completely and accurately as possible.  Once submitted, your information is e-mailed to our office and we will process your request.  This information is kept confidential and used for quote purposes only.

   *Required fields marked in yellow

Contact Information
*Name:
*Address:
*City:  State:  Zip:
*Phone: Work:
 
Home: 
   
 Fax: 
Occupation:
Email Address:

 

Personal Information

Date of Birth: //
Gender: Male   Female
Tobacco User: Yes  No
Height & Weight: ft.in.   Weight:lbs.
Are you a Private Pilot?: Yes  No
Amount Needed:
Policy Type:

Annual Renewable Term

Level Term

\whole Life

Universal Life

Second-To-Die

Not Sure
Policy Duration:

Please describe any and all health conditions, now and in the past:

 

Additional Considerations/Requests
Please add any comments/questions not covered above.


Please click on the "Send Request" button to send us your quote request.

  

 

 

 

 

Home   l   Meet Tim   l   Services   l   Contact

©Copyright 2006-08 Benefits Consultants & Tim Piatchek. All Rights Reserved.

Site Designed and Maintained by Eagles WingWeb Services