DENTAL INSURANCE QUOTE (Customized and personalized) 
APPLICANT         ALL INFORMATION IS CONFIDENTIAL             SPOUSE                          CHILDREN     
First Name:                                                                                  First Name:                                              Number:     

Last Name:                                                                                  Gender:                          

Telephone Number (Including area code):                                               

Email Address:                                                                                            

                                                                                             

                                                                                    

                                                                     

                                                                                                 

                                                              

                        
                                          

                                                                                                     
                                                                                                     
     
                                                     
INSURANCE
ANNUITIES
RETIREMENT INCOME
EMPLOYEE BENEFIT PLANS
WEALTH PRESERVATION
BUSINESS PLANNING
TAX AVOIDANCE STRATEGIES
Is current coverage through an Employer Plan?
Do you currently have a Dentist you don't want to lose? .
List any current dental issues below ! 
Type of Plan:
Resident City:
Currently on Medicare:
Transitioning to:
Resident State:
Resident Zip Code:
I'M ALSO READY TO TAKE ACTION ON:
Are you self-employed? 
Gender:
Smoker:
Age:
Currently on Medicare:
Transitioning to:
Do You Currently Have Dental Insurance?
If YES, What Company?
If YES, Full Name:
Phone Number:
Age:
Are you self-employed? 
Do you have health insurance:
I was referred by:
Michael Mendonca, FLMI
Covered California
Certified Insurance Agent

​Insurance
Annuities
   Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource 
949.954.4445
[email protected]
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