Life

Life Insurance

Insurance Check-ups & Quotes
Insured Name

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Residence & Mailing Address

Please include your mailing address if it differs from your residence address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Who referred you to us?*
Referred by...
Let's be friends

Share your social media handle
Social media*
Ex. @majdastouchinsurance
Insurance Information

Please fill out the following as accurately as possible.
What type of Life Insurance are you looking for?*
Have you had any surgeries or prescriptions in the last 10 years? List them below.*
List any and all surgeries and prescriptions (even the dosages). Please be specific.
How much coverage do you need?*
What is the dollar amount?*
Additional Notes*
Copy of each driver's Drivers License*
Why do you need proof of my identity?
Insurance companies require us to verify the identity of the person who has a legal insurable interest in the item needing to be insured. If it’s a house, we need proof of identity for the person who is on the title of the home. If it’s a car, we need proof of identity from the person who owns the car. Acceptable proof of identity is a copy or a picture of the front of your drivers license or government issued ID (we do not need the barcode). If you want to add additional persons to be covered, for example a spouse or family member who is residing in the property or an additional driver, we need their information as well. If more than one person is listed on a title or ownership records, you can provide proof for only the ones needing to be covered. Without this information we cannot obtain prices on your behalf. We are pulling hundreds of quotes at the same time, for the same policy information, and auditing and compliance standards require us to have proof of your identity first in order to obtain pricing (to prevent fraudulent requests). The same rules apply to commercial insurance, if you are the owner of the business we need your proof of identity to help you.  
Acknowledged and agreed by client:*

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Life Insurance

Insured Name

Residence & Mailing Address

How did you hear about us?

Let's be friends

Insurance Information

Why do you need proof of my identity?