Bejella Agency

Corpus Christi, Texas

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Life Insurance

Although many people view Life Insurance as an expense, at the Bjella Agency we think of it as an investment in protecting the future of your family or your business. For a quick confidential quote on a life insurance policy just complete the following form.

Due to the legalities of insurance, we ask that only residents of the State of Texas submit this form.

Fill in all parts of the form - it will save a lot of time later!

Corpus Christi Beachfront

Life Insurance Inquiry Form

Your Name 

Residential Address 



     Zip Code



Telephone Number

E-mail Address



Current Martial Status

Your Date of Birth

Do You Smoke? 

What is your occupation?



What is your spouse’s Date of Birth?

Does your spouse smoke? 



What type of life insurance would like to  have quoted to you? 

What amount of insurance would like  quoted?  (please do NOT use commas) 


Are you interested in disability income  coverage for your self? 

Are you interested in long term care   insurance for yourself? 

Any other comments or information?



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