Read and sign form below.
Then you will be taken to the a page where you will be able to schedule the time and date of your consultation.

As indicated by the signature(s) on this form, I (we) have been advised and have full knowledge that in applying for insurance with Barker Phillips Jackson Insurance of Missouri providing services, both in person and through technology, to research, quote, select and enroll in individual health insurance coverage, I (we) are paying to Barker Phillips Jackson a per use, non-refundable consulting fee of $150, One hundred fifty dollars, as authorized by SB 193, which amended Chapter 375 of the Revised Missouri Statutes.  In addition to this fee, BPJ may or may not receive some small compensation from the insurer. I (we) further understand and agree that should the application for insurance be rejected, postponed, canceled, rated up, or should I (we) elect for any reason to withdraw or cancel the application for insurance or request the coverage be canceled or the application voided, the service charge is fully earned and that no portion of the service charge will be refunded or returned.

I (we) further agree and understand that if payment for said consulting or application is by personal or business check and should that remittance be returned by any financial institution as non-negotiable for any reason, I (we) agree we will be obligated to pay immediately in cash, cashier’s check, or money order an additional service fee to BPJ Agency the sum of Twenty-Five ($25.00). I (we) understand and agree this fee is in addition to any consulting fee due and payable and is due BPJ Agency regardless of the status of the application or request for insurance services.

    the insurance and financial services we offer include


    Local Knowledge

    Local Knowledge

    Local Knowledge

    BPJ Combines the Financial Security of a Large Corporation with the Best Elements of a Smaller Local Organization

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