Information About the Person to be Insured - Step 1
Name of the Person to be insured:
First Last
Gender
-- Select --
Female
Male
Home Zipcode:
Birth Date:
MM/DD/YYYY Example: 04/20/1956
Height and Weight
feet
inches
pounds
Marital Status:
-- Select --
Single
Married
Divorced
Separated
Widowed
Occupation:
--Select--
Accounting/Bookkeeping
Actor
Administration/Management
Appraiser
Architect
Artist
Assembler
Auditor
Baker
Bank Teller
Banker
Bartender
Broker
Cashier
Casino Worker
CEO
Certified Public Accountant
Chemist
Child Care
Childcare
City Worker
Claims Adjuster
Clergy
Clerical/Technical
College Professor
Comp. Tech.
Construction
Contractor
Counselor
Craftsman/Skilled Worker
CSR
Custodian
Dancer
Decorator
Delivery Driver
Dentist
Director
Disabled
Drivers
Electrician
Engineer-Aeronautical
Engineer-Aerospace
Engineer-Chemical
Engineer-Civil
Engineer-Electrical
Engineer-Gas
Engineer-Geophysical
Engineer-Mechanical
Engineer-Nuclear
Engineer-Other
Engineer-Petroleum
Engineer-Structural
Entertainer
Farmer
Fire Fighter
Flight Attend.
Food Service
Government
Health Care
Housewife/Househusband
Installer
Instructor
Journalist
Journeyman
Lab Tech.
Laborer/Unskilled Worker
Lawyer
Machine Operator
Machinist
Maintenance
Manufacturer
Marketing
Mechanic
Military E1 - E4
Military E5 - E7
Military Officer
Military Other
Model
Nanny
Nurse/CNA
Painter
Para-Legal
Paramedic
Personal Trainer
Photographer
Physician
Pilot
Plumber
Police Officer
Postal Worker
Preacher
Pro Athlete
Production
Programmer
Real Estate
Receptionist
Reservation Agent
Restaurant Manager
Retail
Retired
Roofer
Sales
Scientist
Secretary
Security
Self Employed
Social Worker
Stocker
Store Owner
Student
Stylist
Supervisor
Teacher
Teacher(Credentialed)
Technical/Supervisory
Travel Agent
Truck Driver
Unemployed
Waitress
Welder
(Other)
Annual Income:
--Select--
None
under $10000
$10001 - $20000
$20001 - $30000
$30001 - $50000
$50001 - $75000
$75001 - $100000
over $100000
What type of Life Insurance are you looking for:
Not Sure
Term
Cash Value
Whole Life
Universal Life
For Term Insurance, how many years:
Not Sure
5 yrs
10 yrs
15 yrs
20 yrs
30 yrs
Amount of Insurance (death benefit):
thousand dollars
Your current Life Insurance Company:
None
AAA
AABCO
Acceptance
Access Insurance
Acordia
Aegis Security
Aetna
Affirmative
AHCP
AIG
Aig Allied Amco
All Nation
All Risk
Alliance for Affordable Ins
Allianz
Allied
Allstate
Allstate Indemnity
American Alliance
American Banks
American Economy
American Family
American General
American Healthcare Plan
American Medical Securities
American National
American Premier
American Reliable
American Republic
American Standard
American States
America's Ins. Consultants
Amerisure
Amica
Anthem
API
Arbella
Arizona General
Assigned Risk
Association Field Services
Assurant
Atlanta Casualty
Atlanta Specialty
Atlantic Indemnity
Austin Mutual
Auto Owners
Avomark
Badger Mutual
Bankers & Shippers
Bankers Life and Casualty
Banner Life
Blue Cross
Blue Cross Blue Shield
Bonneville
Boston Old Colony
Brooke Franchise Corporation
Builders
California Casualty
Camden
Capital Choice
Care Entrйe
Cascade National Ins
Casualty Assurance
Centennial
Charter Oak
Chase Insurance Group
Chicago Insurance
Chubb
Church Mutual
Cigna
Citizens
Clarendon
Cloverleaf
CMA
CMA Alliance
CNA
Colonial
Combined
Commercial Union
Commonwealth
Continental
Continental General
Cornerstone Marketing
Cottonwood
Country Insurance
Credit Union
Criterion
CUNA Mutual
Dairyland
Dakota Fire
Deerbrook
Depositors Emcasc
Dixie
Ebco General
Economy
Economy Fire & Casualty
Economy Preferred
Electric Insurance
EMC
Empire
Employers Fire
Ensure
Equitable Life
Erie
Facility
Farm and Ranch
Farm Bureau
Farm Bureau St. Pau
Farmers
Farmland
Federal
Federated
Federated American
Federated Group
Fidelity
Financial Indemnity
Firemans Fund
First American
First Financial
First General
First National
Ford Motor Credit
Foremost
Fortis
Franklin
Geico
GEICO Casualty
Geico Indemnity
General Accident
General Accident Gr
General Casualty
General Insurance
Genworth Financial
Globe
GMAC
Golden Rule
Government Employees
Grange
GRE Harleysville H
Great American
Great Way
Great West
Grinnell Mutual
Guaranty National
Guardian
Guidant Casualty
Guide One
Halcyon
Hanover
Happy Days
Hartford
Hawkeye Security
Health Net
Heritage
High Point
Horace Mann
Humana
IAB
IAB Health Benefits
IDS
IGF Ins.
Infinity
Insur. of Evanston
Integon
Interstate
John Deere
John Hancock
Kemper
Kentucky Central
Leader General
Leader National
League General
Liberty Mutual
Lincoln Benefit Life
Marathon
Markel American
Maryland Casualty
Mass Mutual
Mega Life & Health
MEGA Life and Health
Mendota
Mendota Metropolita
Merastar
Mercury
MetLife
Metropolitan
Mid Century
MidCentury (Farmers)
Mid-Continent Casualty
Midwest Mutual
Mid-West Ntl. Life
Millbank
Millers Mutual
Milwaukee
Milwaukee General
Milwaukee Guardian
Milwaukee Mutual
Minnehoma
Missouri General
Modern Woodmen of America
Mony Group
Mortgage Protection Bureau
Motors
Mountain Laurel
MSI
Mutual Of Enumclaw
Mutual Of Omaha
NASE
Nat Assoc - Self Employed
National Alliance
National Colonial
National Continental
National Indemnity
National Merit
National Surety Corp
Nationwide
Nationwide Mutual
Nat'l Farmers Union
New England Financial
New York Life
North American
North Pacific
North Pointe
North Shore
Northern Capital
Northern States
Northland
Northwest Pacific
Northwestern
Northwestern Mutual
Ohio Casualty
Ohio Security
Olympia
Omaha
Omni Ins.
Oregon Mutual
Orion Ins.
Pafco
Paloverde
Patriot General
Pemco
Penn America
Penn Mutual
Pennsylvania Natl
Phoenix
Pinnacle
Pioneer Life
Preferred Abstainers
Preferred Risk
Preferred Risk Mutua
Premier
Prestige
Primerica
Principal Financial
Progressive
Protective Casualty
Protective Life
Provident
Prudential
Quality
Ramsey
Ranger
RBC Liberty
Regal
Reliance
Reliant
Republic Indemnity
Rockford Mutual
Rodney D. Young
Safeco
Safeway Ins.
Sea West Insurance
Secura
Security National
Sedgwick James
Sentry
Shelter
Skandia TIG Tita
Spectrum
St. Paul Companies
Standard Guaranty
State Auto
State Farm
State Farm Fire & Casualty
State Mutual
State National Ins
States General
Sun Coast
Superior
Sutter
Time
Titan Indemnity
Total
Tower
Travelers
Trinity Universal
Tri-State Consumer
Trust Hall
Twentieth Century
UGA
Unicare
Uniguard
Union
Union Security
United American
United Financial
United Fire & Casual
United Fire/Casualty
United Group Associates
United Health Care
United Security
United Services Auto
United States Fideli
United Wisconsin Life
Unitrin Inc.
Universal Benefit Plans
Universal Marketing
Unsure
US Health Advisors
USAA
USF&G
Utah Home and Fire
Utica
Vasa North Atlantic
Vigilant
Viking
Wawaunesa
Wellington
Wellpoint
West American
West Bend Mutual
West Field
West Plains
Western National
Western Southern Life
Westfield
William Penn
Windsor
Windstar
Wisconsin Mutual
Workmans Auto
Worldwide
Yellow Key
Yosemite
(other or not sure)