Welcome!
We are here to serve you not only as a client but as a new member of our family. Take a moment to help us complete your file by clicking on each tab and completing the information requested.
Back
Next
Emergency Response Service
Currently there is OVER One Billion dollars in unclaimed life insurance money in America. Most unclaimed life insurance is from beneficiaries not knowing that they were a beneficiary on a policy. Emergency Response System is our way of making sure your death claim will be paid immediately to your beneficiaries. THE INSURANCE COMPANIES REQUIRE US TO GET 5.
Agent Name
Your details
Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
ERS #1
Contact Name
First Name
Last Name
Relationship & Date of Birth
Phone Number
-
Area Code
Phone Number
Contact E-mail
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Response
Prescription Assistance
Insurance Needs
Retirement Protection
Medicare/Med Sup Plans
Hospital/Cancer plans
Tell us more about this person
ERS #2
Contact Name
First Name
Last Name
Relationship & Date of Birth
Phone Number
-
Area Code
Phone Number
Contact E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Response
Prescription Assistance
Insurance Needs
Retirement Protection
Medicare/Med Sup Plans
Hospital/Cancer plans
Tell us more about this person
ERS #3
Contact Name
First Name
Last Name
Relationship & Date of Birth
Phone Number
-
Area Code
Phone Number
Contact E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Response
Prescription Assistance
Insurance Needs
Retirement Protection
Medicare/Med Sup Plans
Hospital/Cancer plans
Tell us more about this person
ERS #4
Contact Name
First Name
Last Name
Relationship & Date of Birth
Phone Number
-
Area Code
Phone Number
Contact E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Response
Prescription Assistance
Insurance Needs
Retirement Protection
Medicare/Med Sup Plans
Hospital/Cancer plans
Tell us more about this person
ERS #5
Contact Name
First Name
Last Name
Relationship & Date of Birth
Phone Number
-
Area Code
Phone Number
Contact E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Response
Prescription Assistance
Insurance Needs
Retirement Protection
Medicare/Med Sup Plans
Hospital/Cancer plans
Tell us more about this person
Back
Next
CLient Survey
1. Are you satisfied with the quality of the service that you received?
*
2. Was your agent knowledgeable and able to answer your questions?
*
3. Would you recommend our services to a friend of family member?
*
• If so, who?
4. What suggestions or comments do you have about your experience?
What Products Would you Like to Know More About?
Starting a Retirement
Accessing Money Tax Free
Better Allocation of Monthly Savings
Insurance Retirement Account
Guaranteed Income for Life
Starting a Retirement
Permanent Life Insurance
Options for Parents
Children’s Head Start Program
Options for Grandchildren
Other Insurance Options
Medicare Plans
o Disability Protection
Critical Illness Protection
Health Matching Account
Dental/Vision Plans
Hospital Indemnity
Other Services
Debt Consolidation
Old Life Insurance Policy Evaluation
Additional Income
Becoming a Part Time Agent
Becoming a Full Time Agent
Back
Next
Completed and Submit
Submit
Should be Empty: