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First & Last Name...
  
Gender...
  
Date of Birth... (00-00-0000)
  
Type of Insurance...
  
Term Life
Number of Years Desired...
  
Term Life, Whole Life or Universal Life
Amount of Coverage Desired...
  
Short-Term or Long-Term Disability
Waiting Period Desired...
  
Monthly Income Benefit Desired...
  
Maximum: 60% of Earned Income
Current Health Condition...
  
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
  
Reason for Coverage
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Disclaimer
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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