WE RESPECT YOUR PRIVACY

Your privacy is important to us. Waguespack Insurance considers the protection of your personal information to be a primary goal. We respect your right to keep your personal information confidential.

We collect information in order to quote and service your insurance policy. This information is used only by our company and is not shared with any other vendor from which you could receive a solicitation.

Waguespack & Associates uses Secure Sockets Layer (SSL) protocol to interact with you when you provide personal information during the purchase and payment processes. We handle your information via 64-bit encryption. Every secure page has been secured with a digital certificate generated by COMODO Security. To view this certificate, click on the image of the "closed lock" or the "solid key" on the bottom of your browser window. A small frame displaying site security information will appear.

AS AN INDEPENDENT INSURANCE AGENCY...

we do not work for an insurance company; we work for you. We work on your side when you have a loss and follow through to see that you get a fair, prompt payment.

 

 
Life Insurance Quote Form

To request a quote, please complete the form as completely as possible. If currently insured, your policy's declaration page will have much of the needed information. Type "unsure" in any required field in which you aren't sure of the answer. Your information will be forwarded to our agents, and all information is transferred securely and will be kept confidential.


Contact Information
Name
Street address
City
State
Zip Code
Daytime Phone
Evening Phone
FAX
E-mail Address

Insurance Policy Information
Are you currently insured? CHECK ONE Yes        No*
*If No, please give reason not insured currently. i.e.: First time insured, policy canceled 3 mo's ago, etc.
If yes, by what company?
Policy expiration date?
Length of time continuously insured

Please provide the following information about the person the quote is based on:
This is only if the quote is for someone other than above.
Name
Gender Male  Female
Date of birth (mm/dd/yy)
Height
Weight
Occupation
How much insurance would you like?
Please select the term in years
Supply any additional requirements regarding the amount of insurance
Tobacco Usage

Medical Conditions
If you have ever had any of the medical conditions listed below, please check any that apply.

AIDS or HIV
Alcohol or Drugs
Alzheimer's Disease
Cancer
Chronic Respiratory Disease
Depression
Diabetes
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Hypertension
Kidney or Liver Disease
Mental Illness
Stroke
Ulcerative Colitis
Vascular Disease
Other (Explain Below)

Additional Information
Have you ever been declined or rated for Life or Health Insurance in the last 5 years? Yes   No
Are you currently taking medication? Yes   No
Have you been hospitalized in the last five years? Yes   No
If yes, give details below.

 

Provide any additional information or comments below.