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Name (First & Last):  
Gender:  
Date of Birth:     (00-00-0000)
Type of Insurance:  

Answer if Term Life Was Selected
Years of Coverage Desired:  

Answer if Term Life, Whole Life or Universal Life Was Selected
Amount of Coverage Desired:  

Answer if Short-Term or Long-Term Disability Was Selected
Waiting Period Desired:  
Monthly Income Benefit Desired:  
    Maximum: 60% of Earned Income

Current Health Condition:   Excellent Good Fair Poor
Height:      
Weight:     (200 lb)
Smoked Within Last 2 Years:   Yes No
Other Tabacco Use Last 2 Years:   Yes No
Email Address:  
Phone Number:     (000) 000-0000
Please Explain Reason for Coverage

Ron Knowles and Chad Rodriguez offers securities through Centaurus Financial, Inc. who is a member of FINRA and SIPC. Supervisory office: 540 Fort Evans Road, NE, Suite 200, Leesburg, VA 20176 (800) 880-4234. Please be advised that Safe Money Management, LLC and Centaurus Financial, Inc. are not affiliated. This is not an offer to sell securities. A proposal can only be submitted to a client after the proper delivery of a prospectus and the client's suitability has been reviewed and determined. Information relating to securities is only intended for use by individuals that reside in Louisiana.
 
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