Vincent F. Gauci - VFG Associates,LLC

VFG Associates, LLC

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Call 734-855-4930
or 800-859-4453
Fax 734-855-4933
29432 Joy Road, Livonia, MI 4815

Request Form

Individual Health Insurance Quote Request

Please note: We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.

Please Select your preferred agent.
Agent:
Effective Date:   Email: 
Name:   Daytime Phone#: 
Your Mailing Address: Street   Evening Phone#: 
  Other/Cell Phone#: 
City, State, Zip
 
       
Choose One:  Please call me with quote premium.    
 Please send quote via e-mail.    
Do you have health
insurance now?
 No  
Yes    Current company:     Expires:
Applicant Information:
Male Female
Birthdate:
Height:
Weight:
Tobacco Products:
To your knowledge, have you shown any signs of cardiovascular disease before the age of 60? Yes No
Do you have any pre-existing medical conditions? Yes No
Do you currently take any medications? Yes No
If yes, what medication.
Are you, your spouse or any dependents now pregnant? Yes No
Policy Options:
Deductible Requested: Co-Pay Requested:
Optional Coverages: (Check all that apply.)
Hospital Insurance Supplemental Accident
Long Term Care Disability Insurance
Prescription Card Maternity
Senior Care Life Insurance
Include Spouse in Quote? Yes No
If yes:
Male Female  
Birthdate:
Height:
Weight:
Tobacco Products:
Include Children in Quote? Yes No
If yes:
Child 1 Male Female Birthdate:
Child 2 Male Female Birthdate:
Child 3 Male Female Birthdate:
Child 4 Male Female Birthdate:
Child 5 Male Female Birthdate:
Comments or Questions:

Protecting your privacy and identity is very important to us. 
Social Security and drivers license numbers may be required to complete this quote.   Please be sure you have provided an accurate contact number so that we can contact you personally for this information.


If you have not received a response from us within one business day, please contact us again. Thank you.

Securities Offered Through KCD Financial,Inc. Member FINRA & SIPC, 3313 S. Packerland Drive, Suite E, DePere, WI 54115