Order Insurance Windfall !
ORDER FORM for INSURANCE


Please print and RETURN this portion below. If printer does not print, or you don't have a printer, please send your name, address, phone number and EMAIL ADDRESS (legibly printed) and mail to address below.
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APPLICATION FORM

or Money Order Or Cash - (USPS MO is considered cash and gives immediate delivery)

YOUR PERSONAL CHECK WELCOME !

For orders outside USA please only send International Money Orders payable through a USA Bank. Thanks.

Send to:

If I cannot collect on Insurance as you say, I want my money refunded.

Enclosed is $33 for Transferring cash from Insurance to my Account. (ref. cleanfile.com).
Enclosed is $2 extra for priority handling.

NAME:
ADDRESS:
CITY: STATE:
ZIP: AREACODE/PHONE:
EMAIL:(print)
How did you find us (search engine, kywrds., etc.)?:

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