LRC and Associates


 Use this form to request your Critical Advantage and Cancer/Heart attack plan quotes.  Call with any questions - 1-800-443-5149

* Required fields
Name *
E-mail Address *
Client's Name *
Coverage Type *
Spouse's Name (if applicable)
Cilent's DOB or age Last Birthday *
Spouse's DOB or age Last Birthday (if applying)
Plan *
Base Lump Sum Benefit Amount (between $10,000 & $100,000 in $1,000 increments) *
Lump Sum Heart Attack & Stroke Amount (between $10,000 & $100,000 in $1,000 increments)

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