(909) 543-1818 Redlands, CA

Rick Plata Insurance Agency

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Insured Information

Name*

Date of Birth*

Gender
Male Female

Tobacco Use?
Yes No

Phone Number*

Email*

Street Address*

City*

State*

Zip*

Spouse Name

Date of Birth

Gender
Male Female

Tobacco Use?
Yes No

Child 1

Date of Birth*

Gender
Male Female

Child 2

Date of Birth*

Gender
Male Female

Child 3

Date of Birth*

Gender
Male Female

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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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