(909) 543-1818 Redlands, CA

Rick Plata Insurance Agency

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Gender
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Tobacco Use?
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Child 1

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Male Female

Child 2

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Male Female

Child 3

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Gender
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Amount of Death Benefit

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Use Tobacco
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Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Rick Plata Insurance Agency | 1255 W. Colton Ave., Suite 501 | Redlands, CA 92374 | (888) 235-8060 | (909) 543-1818

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