AGIS - Promotions - Total Sports Fan

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Contest Validation Form

Example

Client	Premium	Type
1. Client A	13,051	Life
2. Client B	400,000	Annuity
3. Client C	1,300	Medicare

Complete the following form and click send, or print and fax to 972.458.4582. If necessary, complete form multiple times.

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Agent Information
Name
Address

City
State
Zip
Phone #
Comments
E-mail address