Whole Life Insurance Illustration Request
DISCLAIMER:
 The following quote is not an offer of life insurance and is subject to the underwriting approval of the individual insurance company. If a life insurance offer  is made, the actual premium may differ from the illustration resulting from this request.

Request Illustration From

Please select the Agent Support office nearest you or the office you are currently affiliated with:  (Required)
 Agent Support New York City           
   Agent Support Long Island
   Agent Support Westchester             
   Agent Support Connecticut

Agent Information

Agent Name    (Required)
Email Address (Required if fax is unavailable)
Fax                 (Optional)
Phone             (Optional)

I would like you to send my illustration/quote by       
                     Fax        Email      (Required)

Carrier(s) Requested 
(To select multiple companies, press the CTRL while making your selection)                                  

 

Client Information

Client Name         

DOB/Age             

Sex                     
State                   
Underwriting Class
Tobacco Type       
Medications  

Medical History

Family History 

 

Second Insured (This option is only for Survivor Life)

Client Name         

DOB/Age             

Sex                     
State                   
Underwriting Class
Tobacco Type       
Medications 

Medical History

Family History  

 

Policy Information

Billing Mode

Death Benefits $

Solved or Specified Premium To Pay $

Solved or Specified Number of Years To Pay

       Percentage Term %
Natural Premium Offset With Current Dividend
Or Percentage of Lower Dividend %
Dividend Option

1035 Exchange Amount $

Lump Sum First Year Dump In $

Waiver of Premium
Comments or Other Calculations

 



 

Quotes:               Run real-time online quotes from different carriers.

Request  Illustration Illustrations can be emailed and/or faxed to you.  For real-time illustrations, please use WinFlex Web.

WinFlex Web: WinFlex Web enables agents to run illustrations online  from different insurance carriers. You have to register initially to be able to login. During the registration process, make sure to select Agent Support Group as your Agency/BGA.