Your Licensed Agent

Darlene Duran

Licensed Insurance Agent

(813) 270-4214Call

Health Plus One

Client Intake Form

Welcome! Darlene Duran has sent you this form to gather your details so we can find the best coverage for you.

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Your Information

First Name *

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Last Name *

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Date of Birth

Phone *

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Street Address

City

State

ZIP

Authorization & Consent

By completing this intake form, I authorize Health Plus One Agency and its licensed agents to contact me regarding health and life insurance products by phone or email. The information I provide will be used solely to help match me with appropriate coverage options.

I understand that sensitive information (such as Social Security Numbers) is not collected on this form and will only be requested at the time of a formal application through the carrier's secure enrollment system.

Text-message (SMS) follow-up is optional — you will be asked on the final step whether you consent to receive SMS. This is a solicitation for insurance. You may opt out of future communications at any time by replying STOP to any text message or contacting us at 813-445-3307. See our SMS Consent Policy. SMS Consent Policy.

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