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Due to Security Reasons, Payment Information is Not Collected over the Web. All information is considered confidential. By filling out this form we consider there to be an understanding between you and Multi---Lines Insurance Agency that you are not obligated to purchase this policy, that this is just a request for a quote. If you do decide to purchase at our low prices, we will deliver your policy to you. Due to the nature of the Internet and E-mail, delivery of this form cannot be one hundred percent guaranteed. If you do not receive a reply from Multi---Lines Insurance about your submission of this form within a reasonable number of working days (or if you have any questions), please contact Multi---Lines Insurance Agency by emailing sdcunha@embarqmail.com, or give us a call during regular business hours at (850) 906-0663.

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Section 2, Dental Plan **.

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Section 3, Accident Disability Income Plan**.

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Multi-Lines Agency, Post Office Box 12082, Tallahassee, Florida 32317
Phone or Fax (850) 906-0662