I, , consent to Agent providing my personal and confidential information to Broker/Agent, Sonia Beato, who will act as the agent for ancillary plans. I authorize the Broker, Sonia Beato, to electronically complete my application. I attest that I currently have a health insurance and the Indemnity plans DO NOT REPLACE my Health Insurance. I am the principal in the plan(s) and fully understand them.
I approve the payment of my chosen plan(s) as follows:
Chosen plan(s) indicated by an X mark next to the product.
DENTAL _____
FLORIDA COMBINES LIFE FOR DENTAL TOTAL $
ACCIDENT _____ HOSPITAL _____ CRITICAL CARE _____
UsABLE FOR ACCIDENT TOTAL $
UsABLE FOR HOSPITAL PLAN TOTAL $
UsABLE FOR CRITICAL CARE PLAN TOTAL $
Payment information:
Routing number:
Bank account:
I authorize recurring monthly payments:
Agency: 1 Key Insurance Solutions
Agent: Sonia Beato
Telephone: 7866156553
