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

Life Insurance Quote Request

Please Select your preferred agent.
Effective Date:
Your Name:
Your Mailing Address: Street

City, State, Zip
E-mail Address:
Daytime Phone #:
Choose One:  Please call me with quote premium.
 Please send quote via e-mail.
Current coverage: Company: 
Expiration Date:
Plan Desired:
You: Your Spouse:
Term Life: Term Life:
Permanent Life:  Permanent Life: 
Amt. of coverage: Amt. of coverage:
Payment Type:  Annually  Quarterly  Monthly
Monthly or annual premium amount:
Maximum number of years for payment:
Options Desired:
Waiver of Premium if Disabled? Yes   No
Accidental Death Benefit? Yes   No
Spouse Term Rider? Yes   No Amount:
Children’s Life Rider? Yes   No Amount:
Return of Premium on Term Plan? Yes   No
Terminal Illness Accelerated Benefit on Permanent Plan? Yes   No
Long-Term Care Benefit on Permanent Plan?   Yes   No
Applicant Information:
Applicant: Male Female Spouse: Male Female
Date of Birth: Date of Birth:
Height: Height:
Weight: Weight:
Tobacco products: Tobacco products:
#1 Birthdate: #4 Birthdate:
#2 Birthdate: #5 Birthdate:
#3 Birthdate: #6 Birthdate:
Present or past treatment or conditions:
For Heart Disease, Cancer or Diabetes?

Any family history of cardiovascular disease before the age of 60?

Present or past treatment or conditions for blood pressure, cholesterol, hypertension, depression?

Sky diving/hang gliding/scuba diving/hazardous occupation?

Any current medical condition/medications?  (Please list below.)
Current Medications & Dosage (Mg./Day):
Additional Questions/Comments
Please use the box below to enter any additional information you wish to include:

Protecting your privacy and identity is very important to us. 
Your Social Security number is required to complete this quote.  We will contact you personally at the number you have provided 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