The Standard Quoter Form - Shoreline Financial Group

Available Riders

Spouse & Child Riders
If adding a Spouse Rider. - NOTE: Spouse must certify that they are actively at work now, for wage or profit, and they have worked at least 20 hours each week performing all duties of my regular occupation at their regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy.* ELIGIBLE for 1 of 3 amounts, $10,000, $20,000 or $30,000 if working. Only $10,000 if not working.
YesNo
Since you do not have a Spouse Rider, please continue to the next page.

Billing Information
YesNo
Payor Details
Payor Name*

First NameLast Name
Relationship to insured?*
Payor Email Address*
example@example.com
Payor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ACH Banking Information
Name on Account*

First NameLast Name
Routing Number*
Account Number*
If the account address is different than your mailing address, please provide the address here. (If the address is the same, please state "SAME" here.)*
CheckingSavings
IMPORTANT: Policy Effective Dates and Payment Method

Payment must be made between the day of enrollment and the 24th of the month to have an effective date of the following month.
Effective Date
Yes

Based on the information you have provided, you should qualify for the Complete Whole Life Insurance policy.
If you have any additional information you wish to provide, please add it here.
Mandatory Disclosures

Please read each of the following disclosures and agree and sign to be able to continue your application process.
The Standard, American Heritage Life Insurance Company Agreement
You must read and agree to the "The Standard" Agreement.

Please view this agreement at THIS LINK.
Yes, I have read and agree to the above linked document.
Full Name
Signature*

Clear
Date

MonthDayYear
Date

If you have any additional information you wish to provide, please add it here.
SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR CHRONIC ILLNESS RIDER
You must read and agree to the SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR CHRONIC ILLNESS RIDER Agreement.

Please view this agreement at THIS LINK.
Yes, I have read and agree to the above linked document.
Full Name
Signature

Clear
Date

MonthDayYear
Date

SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS OR CONDITION RIDER
You must read and agree to the SUMMARY and DISCLOSURE STATEMENT for ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS OR CONDITION RIDER Agreement.

Please view this agreement at THIS LINK.
Yes, I have read and agree to the above linked document.
Full Name
Signature

Clear
Date

MonthDayYear
Date

Final STATEMENT and any Questions
Yes
Full Name
Signature - Final Statement and any Questions*

Clear
Please sign using your mouse.
Today's Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Complete Whole Life Application