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Lic # 0D44460

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Authorized broker for Viking Insurance, Infinity, DriveInsurance from Progressive, AIG, and Bristol West.

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Galaxy Insurance Service Inc
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Health & Life Quote

Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

HEALTH QUOTE
Bold = Required field
Effective Date
APPLICANT
First Name
Middle
Last Name
Address
City
Zip Code
Zip Code
City
Mailing Address
Phone
Fax
Email
Date of Birth
SPOUSE
Last Name
Middle
First Name
Date of Birth
Date of Birth
First Name
Middle
Last Name
CHILD
CHILD
Last Name
Middle
First Name
Date of Birth
CHILD
Last Name
Middle
First Name
Date of Birth
CHILD
Last Name
Middle
First Name
Date of Birth
LIFE QUOTE
Last Name
Middle
First Name
APPLICANT
Email
Fax
Phone
Date of Birth
Coverage Limit
Term
Any Following Conditions
Additional Information or Comment:
Sex
Sex
Sex
Sex
Type of Coverage
HMO
PPO
Smoke
Yes
No
Whole Life
Yes
No
Sex
Email Address
lnk