(503) 537-6168
Carlton, OR
We support the brave people of Ukraine in their fight to save their freedom and democracy
Payne Insurance & Financial Services
We support the brave people of Ukraine in their fight to save their freedom and democracy
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Gender
Male
Female
Tobacco Use?
Yes
No
Child 1
Date of Birth
*
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Gender
Male
Female
Child 2
Date of Birth
*
Jan
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Gender
Male
Female
Child 3
Date of Birth
*
Jan
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May
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1
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Gender
Male
Female
Amount of Death Benefit
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1,000,000+
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Gender
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Female
Date of Birth
Height
Weight
List medications and reasons
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