Edouard Insurance Agency

Health/Life Quote

Life Insurance Information
Type
Amount of Death Benefit
Insured Information
Insured Name
Address
City
State
Zip
Home Phone
Email
Use Tobacco Yes  No
Gender Male  Female
Height
Weight
Insured Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Spouse Insurance Information
Spouse to be Insured? Yes  No
Spouse Use Tobacco? Yes  No
Gender Male  Female
Height
Weight
Children Yes  No
Spouse Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Children Information
  Date of Birth Gender
Child 1 Male  Female
Child 2 Male  Female
Child 3 Male  Female
Children Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency Weekly  Monthly  Yearly
Other Disability Coverage? Yes  No
Other Disability Coverage Type Individual  Group
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD

Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

"Serving New York  and surrounding areas since 1987"

70 South Main Street
Spring Valley, NY 10977
Phone: (845) 426-0868

Insurance News

Fri, 14 Oct 2011 21:38:05 GMT
Valentine’s Day is upon us, and thoughts of people everywhere turn to… jewelry. Those who don’t buy shiny things for Valentine’s Day may prefer other types of valuables, such as electronics, artwork, antiques, wine and furs. All totaled Valent...
Wed, 25 Jan 2012 13:05:48 GMT
Most people know that a homeowners or renter’s insurance policy is crucial when it comes to protecting your home from a fire or other disaster. However, if you want to safeguard your valuables from the unexpected, there’s another important documen...
Fri, 03 Feb 2012 18:37:29 GMT
Hosting a Super Bowl party is a great way to cheer on your team if you can’t make it to the stadium in Indianapolis this Sunday, but make sure you know and manage the risks of hosting the big game day party. In many states, individuals hosting parti...
Fri, 14 Oct 2011 21:38:05 GMT
Eliminating the chaos that comes along with managing so many different policies is a major advantage of using a Trusted Choice® insurance agent. Placing your business insurance through a Trusted Choice® agent brings someone onto your team who can br...
Fri, 14 Oct 2011 21:38:04 GMT
Millions of Americans donate time—their most valuable asset—to serve as a volunteer board member on non-profits, booster clubs, churches, PTAs and civic organizations, just to name a few. The decisions these folks make can have a dramatic impact o...