Please complete the following form and submit to Buffalo Agency to receive a free no obligation comprehensive insurance quote.  A Life Insurance specialist will contact you from the Buffalo Agency.

Per Our Privacy Policy, we will never sell  your personal information to a third party. All information is confidential and for the sole use of Buffalo Insurance to provide your quote.

LIFE INSURANCE QUOTE
Agent Preference or Agent you are currently working with:	*	JD Buffalo Todd Parker No Preference
TELL US ABOUT YOU
Last Name	*
First Name	*
Street Address	*
City	*	State:* AR OK TN TXZip:*
Contact Number:	*	Secondary Number:
EMAIL	*
RE-ENTER EMAIL	*
Date of Birth (Month/Year)	*	- - Choose One - - January February March April May June July August September October November December
Year	*
GENDER	*	MALE FEMALE
Height	*
Weight
Tobbaco Usage?	*	Yes No
Describe any major health issues:
TELL US ABOUT YOUR INSURANCE NEEDS
How much life insurance do you want us to quote?	*
Which Life Plan?		10 Year Term Life 20 Year Term Life 30 Year Term Life (Not available after age 40) Universal Life Whole Life Return of Premium Term I Am Unsure - Need Advice
CURRENT LIFE INSURANCE
Total Life Insurance on you now?
Are you planning on cancelling any existing life insurance?		YES NO
Do you have group life insurance through work?	*	YES NO
HOW ELSE CAN WE HELP YOU TODAY?
Some of our clients have saved over 20% on their auto and home insurance by letting us shop for a better rate or by combining coverages.
Would you like us to see if we can save you money on your AUTO insurance?	*	YES NO
Would you like us to see if we can save you money on your HOME insurance?	*	YES NO
Do you need a Health insurance quote?	*	YES NO
Do you need a Long Term Care insurance quote?	*	YES NO
Do you need a LIFE insurance quote?	*	YES NO
Security Code	*