(661) 871-9504 Bakersfield, CA

James D. Miller. Jr. Insurance Agency

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Tobacco Use?
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Child 1

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Male Female

Child 2

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Gender
Male Female

Child 3

Date of Birth *

Gender
Male Female

Amount of Death Benefit

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Use Tobacco
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Gender
Male Female

Date of Birth

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Weight

List medications and reasons

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James D. Miller. Jr. Insurance Agency | 1527 19th Street, Suite 410 | Bakersfield, CA 93301 | (661) 871-9504

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