eSignAssist Option 2

eSignAssist Option 2

I will utilize the concierge service and complete an application over the phone with my client and a Shaw American representative. (Minimum $5,000 annualized premium)
I would like to request the following additional services to be completed after the interview.

DocuSign - Shaw American will submit completed forms to you and your client for electronic signatures. Prescription Drug Check - Please request my client's prescription history using Shaw American's RX Account. Human API - Shaw American will contact your client and help them to establish an account to download their medical records. This service enables transmission of client's medical records within 24-72 hours, instead of 4-6 weeks.
Please, submit this form prior to calling.

Conference in your client and call us anytime, Monday through Friday 9:00 a.m. - 4:00 p.m.
When can we expect your call? *

Month Day Year
Date Hour Minutes AM/PM Option
Click below for an ASAP appointment, and we will watch for your call in the next 15 minutes.

ASAP Appointment
Client Information
Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Or Age
Sex? *

Male Female
State of Residence *
Phone Number *

Area Code Phone Number
Email *
example@example.com
Proposed Coverage
Carrier *
Face Amount *
Plan of Insurance *
If Term, Years *
Class Quoted *
Premium Quoted *
Riders?
Will a 3rd party own this policy? (If yes, complete the questions below)

Yes No
3rd party owner type?

Individual Corporation Revocable Trust Irrevocable Trust
Who will be signing on behalf of the 3rd party?
Name
Title
Email
example@example.com
Advisor Information
Advisor Name *

First Name Last Name
Cell Phone: *

Area Code Phone Number
Email *
example@example.com
Last 4 Digits SSN *
How long have you known the client? *
Please, contact me so that I may be contracted with this carrier.

Click Here
Additional Comments
Should be Empty:

eSignAssist Option 2

Client Information

Proposed Coverage

Advisor Information