Life Insurance

At the Eigel Agency, we strive to meet all of our clients’ needs. As a result, we’ve brought in a dedicated Life Insurance expert to ensure you have the guidance and support you deserve when it comes to protecting your future.

When you work with Mario Garcia, Life Insurance expert at the Eigel Agency, you’re getting more than a policy — you’re getting personalized guidance from someone who truly cares. With years of experience and a deep understanding of what matters most to families, Mario takes the time to listen, educate, and tailor solutions that fit your life and future goals. His commitment to service and trust makes planning for tomorrow feel clear and confident today.

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If you have any questions, please don’t hesitate to contact us.

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What are you interested in?

Full Name

Residential Address

Cell Phone and Email Address

Date of Birth

Country & Sate of Birth

Drivers License and State of Birth

Height

Weight

Beneficiary

Beneficiary Date of Birth & Residential Address

Is the Proposed Insured currently Employed? If so, list employer, years employed, and annual earned income?

Does the Proposed Insured have life insurance in force?

Yes No

Does you have a primary care physician?

Yes No

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Medical Questions: If any of the following apply to you, please provide details in the text box below. If not, please type “N/A”.

Have you lost more than 15 pounds in the past 12 months?

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Do you have any congenital or birth defects?

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Do you have any congenital or birth defects?

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In the past 5 years have you been treated for or dianosed with:

High blood pressure or high cholesterol
Chest pain, heart attack, stroke, TIA, or any other heart disease
Cancer or any malignant or benign growth
Diabetes or other blood disorder
Disorder of the liver, pancreas, digestive system or spleen (cirrhosis, fatty liver, weight loss surgery)
Depression, anxiety, stress, eating disorder, ADD, bipolar
Seizures, paralysis, multiple sclerosis, memory loss
Asthma, emphysema, chronic bronchitis, sleep apnea
Kidney, bladder, urinary, reproductive organ or prostate disorder
Arthritis, fibromyalgia, gout, lupus

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Do you currently drink alcohol?

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In the past 5 years have you been diagnosed or treated by a medical professional for any other illness, disease or injury not listed above?

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Have you ever attempted suicide?

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Parent #1 – Still Living?

Yes

Parent #2 – Still Living?

Yes

Total # of Siblings:

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SUBMIT