INSURANCE MADE EASY©

COVER YOUR WORLD

Allen/Freeman/McDonnell Agency

will be happy to quote your

LIFE AND DISABILITY INCOME INSURANCE.

Be advised that we are only licensed to provide insurance in Maine. Please answer each question that follows and then send the form to us over the net. We will try to contact you within 24-hours. Thanks for considering

Allen/Freeman/McDonnell Agency.

Items with an asterick (*) beside them indicate a question that must be answered to receive a quote.

Information About You

First Name:* Middle Initial or Name:

Last Name:*

Address:*

City:* State:* Zip Code:*

Phone:* FAX: E-Mail:*

How do you wish to be contacted?

Life Insurance Request

Client:
Insured #1
Name:*	Birthdate:*	Height:*	Weight:*
Gender:*Male Female	Tobacco Use:*None Pipe Cigar Chewing Cigarettes		If quit, last used.
Medical Conditions:*
Medications & Dosages:*


Insured #2
Name:	Birthdate:	Height:	Weight:
Gender:Male Female	Tobacco Use:None Pipe Cigar Chewing Cigarettes		If quit, last used.
Medical Conditions:
Medications & Dosages:



Product type requested: Permanent Term 5 Year 10 Year 15 Year 20 Year 30 Year	Payment Mode: Annual Semi-Annual Quarterly Monthly Bank Draft



Do you currently have any Disability Income Protection:		Marital Status:
If yes:Individual Group		Current Insurance Carrier
How much per month:$		For How Long? yrs
Waiting Period:		Policy Renewal Date?
Benefit Period:
Occupation:	Annual Salary:
How much of a benefit do you need monthly:*

Please give us any additional information or questions about Life Insurance and let us know how we can best serve you. We may have to call or E-mail you with the additional questions.

How did you find our web site?

Thanks for your request! Just click on the SEND button below to send it to us!

NOTICE: Please be advised that insurance coverage cannot be changed or bound by submitting or leaving an electronic message or voice mail message.

Allen/Freeman/McDonnell Agency

or its parent company, Insurance Made Easy, Inc. does not resell or distribute your personal information in any form. We use the information from this form exclusively to try to provide you the insurance coverages which you are requesting. In completing this form, you give us premission to telephone you, if needed.