Ayres and French Sedona Insurance
Since 1952

Ayres and French Insurance, Inc.
People Serving People...

For all your Sedona Insurance Needs
reply@sedonainsurance.com 928-282-7191

Life and Health Insurance

Dick French, Sr.

Dick French Sr.

Betty French

Betty French

Dick French, Jr.

Dick French, Jr.

John K. French

John K. French

Kathryn

kathryn

Cheryl Henriksen

Cheryl Henriksen

We're Here When You
Need Us!

Ayres and French for Sedona Insurance

Ayres and French Insurance, Inc.
Your Sedona Insurance Agency

A full-service Sedona Insurance Agency
providing coverage to Northern Arizona
since 1952.

Life and Health Insurance

Betty French talks about
Life and Health Insurance.

At some time in every person's life he or she will need both Life and Health Insurance. Life insurance gives to a person's heirs or estate funds previously chosen to pay off debts, or money to be used as the heirs or estate wishes.

Health insurance can pay a persons medical expenses for sickness or accidents. Medicare is an example of a type of health insurance. Medicare supplements normally will pay costs the basic Medicare polices do not.

We have professionals who not only understand the Life and Health business but also understand the medical lingo (two former RN's).

Life and Health Insurance Quote Form

For the fastest and most accurate life and health insurance quote, please provide as much information as possible in the form below.

This information will be kept confidential and will be used for QUOTE PURPOSES ONLY!

General Information

Name:
Address:
City:	State: ZIP:
County:
Phone Day:	Evening Phone:
Best time to call:	AM PM SSN:
Email Address:

About Yourself:

Date of Birth	Sex	Marital Status	Occupation	Height	Weight	Do you smoke?
	M F	M S		Feet Inches	lbs	Y N

Have you have had any of the following health conditions:
Heart Cancer Diabetes HBP

Are you currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions you have (or had in the past):

About Your Spouse: (Only if he or she is to be covered):

Name	Date of Birth	Sex	Occupation	Height	Weight	Does she or he smoke?
		M F		Feet Inches	lbs	Y N

Has she or he had any of the following health conditions:
Heart Cancer Diabetes HBP

Is she or he currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions your spouse has (or had in the past):

About Child 1: (Only if he or she is to be covered):

Name	Date of Birth	Sex	Occupation	Height	Weight	Does she or he smoke?
		M F		Feet Inches	lbs	Y N

Has she or he had any of the following health conditions:
Heart Cancer Diabetes HBP

Is she or he currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions your spouse has (or had in the past):

About Child 2: (Only if he or she is to be covered):

Name	Date of Birth	Sex	Occupation	Height	Weight	Does she or he smoke?
		M F		Feet Inches	lbs	Y N

Has she or he had any of the following health conditions:
Heart Cancer Diabetes HBP

Is she or he currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions your spouse has (or had in the past):

About Child 3: (Only if he or she is to be covered):

Name	Date of Birth	Sex	Occupation	Height	Weight	Does she or he smoke?
		M F		Feet Inches	lbs	Y N

Has she or he had any of the following health conditions:
Heart Cancer Diabetes HBP

Is she or he currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions your spouse has (or had in the past):

About Child 4: (Only if he or she is to be covered):

Name	Date of Birth	Sex	Occupation	Height	Weight	Does she or he smoke?
		M F		Feet Inches	lbs	Y N

Has she or he had any of the following health conditions:
Heart Cancer Diabetes HBP

Is she or he currently on any prescription medications for on-going health conditions?

Yes No If yes, please list:

Please DISCLOSE any and all health conditions your spouse has (or had in the past):

Please select the following coverages:

LIFE Coverages

Please select if interested in LIFE coverage.

Amount of Coverage (self):
Amount of Coverage (spouse):
Amount of Coverage (per child):
Type of Coverage:	Term Whole Universal
Disability Income Coverage?	Y N
Long term care coverage?	Y N
Coverage for:	Self Spouse Child #1 Child #2 Child #3 Child #4

HEALTH Coverages

Please select if interested in HEALTH coverage.

High deductible catastrophic plan:	Y N
No deductible co-pays:	Y N
Maternity:	Y N
Mental Health:	Y N
Chiropractic:	Y N
Acupuncture:	Y N
Dental:	Y N
Vision:	Y N
Preventative:	Y N
Coverage for:	Self Spouse Child #1 Child #2 Child #3 Child #4

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this Life and Health quote form. One of our representatives will respond as soon as possible!

Independent Insurance Agents

Ayres and French, Inc. is a member both of the Independent Insurance Agents and Brokers of Arizona and the Independent Insurance Agents of America.

Ayres & French Inc.
1785 W. 89-A
Sedona, AZ 86336

reply@sedonainsurance.com

Mail To:
Ayres & French, Inc.,
P.O. Box 990
Sedona, AZ 86339

928-282-7191
Fax: 928-282-7338

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