Good Life IA Contracting Request Form

1
Name of Individual Requesting Contract* This field is required.Please complete
First Name
Last Name
2
Contact Phone Number* This field is required.Please enter Phone Number
3
Contact E-mail Address* This field is required.(Assistant or Rep who will handle potential pending items)
4
Which product line are you requesting?* This field is required.
Annuity
Long-Term Care/Short-Term Care
Dental/Vision
Life Insurance (Fully & Simplified)
Disability Income
Medicare Supplement
Medicare Advantage (Part C)
5
Please select a Dental/Vision Carrier* This field is required.One request per form
Please select one
Please select one
Ameritas (Dental & Vision)
Medico (Dental & Vision)
Mutual of Omaha (Dental & Vision)
SureBridge
6
Please select a Medicare Advantage Carrier* This field is required.Only one carrier per form
Please select one
Please select one
AARP (United Health Care)
Aetna
Centene
Cigna
Humana
Well Care
7
Please select a Disability Income Carrier* This field is required.Only one request per form
Please select one
Please select one
Ameritas (Disability)
Assurity (Disability)
Cincinnati (DI)
Fidelity (Disability)
Guardian Life
Illinois Mutual (Disability)
Mass Mutual (DI)
Mutual of Omaha (Disability)
Principal (Disability)
The Standard (Disability)
8
Please select an Annuity Carrier* This field is required.Only One Request per form
Please select one
Please select one
American Equity (Annuity)
American General (Annuity)
Athene (Annuity)
Atlantic Coast Life (Annuity)
Cincinnati (Annuity)
Delaware Life (Annuity)
Fidelity & Guarantee (Annuity)
Global Atlantic (Forethought)
Guggenheim (Annuity)
Integrity (Annuity)
Liberty Bankers (Annuity)
Lincoln Financial (Annuity)
Mass Mutual (Annuity)
MetLife (Brighthouse Financial)
Minnesota/Securian (Annuity)
North American (Annuity)
Oxford (Annuity)
Phoenix Life (Annuity)
Principal (Annuity)
Penn Mutual (Annuity)
Protective (Annuity)
Royal Neighbors (Annuity)
Sagicor (Annuity)
Securian (Annuity)
Sentinel Life (Annuity)
State Life (One America)
Symetra (Annuities)
The Standard (Annuity)
Voya (Annuity)
9
Please select a Life Carrier* This field is required.Both Simplified and Fully Underwritten available (One request per form)
Please select one
Please select one
Accordia
Allianz
American Continental (Simplified Life)
American General (Life)
American National
Americo (Final Expense)
Amicable Life
Assurity (Life)
AXA
Baltimore Life
Banner Life
Cincinnati (Life)
CSI Life (Final Expense)
Foresters
Gerber (Final Expense)
Guardian Life
John Hancock (Life)
Kemper Life
Lafayette (Simplified Life)
Lincoln Financial (Life)
Loyal American (Simplified Life)
Mass Mutual (Life)
Medico (Simplified Life)
Minnesota (Life)
Mutual of Omaha (Life)
Mutual of Omaha (Simplified Life)
National Life
National Western
Nationwide
North American (Life)
Ohio National
Oxford (Life)
Oxford (Simplified Life)
Penn Mutual (Life)
Principal (Life)
Protective (Life)
Prudential
Royal Neighbors (Life)
Sagicor (Life)
Sentinel Life (Simplified Life)
Symetra (Life)
Transamerica (Life)
Transpremier Life (Simplified Life)
United Home Life (Simplified Life)
10
Please select a Long-Term/Short-Term Care Carrier* This field is required.Only one request per form
Please select one
Please select one
Aetna (Short Term Care)
Cigna (Short Term Care)
John Hancock (LTC)
Medico (Short Term Care)
Mutual of Omaha (LTC)
Transamerica (LTC)
11
Please select a Medicare Supplement Carrier* This field is required.Only one request per form
Please select one
Please select one
Aetna (Medicare)
Americo (Medicare Supplement)
Bankers Fidelity (Medicare)
Capital Blue – BC & BS (PA only)
Capital Blue- BC & BS (NC only)
Cigna (Medicare)
Combined (Medicare)
Gerber (Medicare Supplements)
LCBA (Loyal Christian Benefit Association)
Liberty Bankers (Medicare Supplement)
Lumico (Medicare Supplement)
Manhattan Life (Medicare)
Medico (Medicare)
Mutual of Omaha (Medicare Supplement)
New Era (Medicare)
Sentinel Security Life (Medicare)
Thrivent Financial (Medicare)
Transamerica (Medicare)
Union Security (Medicare Supplement)
United American
United Health Care
Western United
12
(Optional) Additional information for the contracting department?Please provide desired states where appointment is needed
13
Enter the message as it's shown* This field is required.
Should be Empty: