Gary E. Krouse Insurance Services, Inc.
9620 Topanga Canyon Place
Suite H
Chatsworth, CA 91311
Phone: (818) 407-5300
Fax: (818) 407-5308
E-mail: License Number: 0C08441

Losing your home is a real risk. We often fail to protect this most important asset. Upon the death of you or your spouse, mortgage protection insurance provides a benefit that will pay off your mortgage balance; leaving your family without mortgage payments and/or other debts. Please complete the information below for your no obligation quote.

  Date of Birth Height Weight
Borrower: / /   ’ (ft) ” (in)
Smoker:  Yes
  Date of Birth Height Weight
Co-Borrower: / /   ’ (ft) ” (in)
Smoker:  Yes
Mortgage Balance:
Mortgage Term: 30 Years
15 Years
Other Term
Person to Contact:
Home Phone:
Work Phone:
Cell Phone:
Best way to contact:   Home Phone
 Work Phone
 Mobile Phone
 No Preference
Best time to call:  Morning
 No Preference
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