NET New Request Life, DI & Other | Equitas Brokerage Group

Life Insurance

Download the form below, or fill out form online!

Life Quote Request Form

Life Quote Form

Broker Name*

My Location

My Email*

Client/Name of Insured

State

Height (ft)*

Weight (lbs)*

Is Client on Medication?

Has your Client recently been hospitalized?

Family History of Heart Disease or Cancer?

Choose the type (or types) of policy your client is interested in:

Whole Life

Check If Applicable

Universal Life

Check If Applicable

Term

10 Year
20 Year
30 Year

Term Riders

Return of Premium
Waiver of Premium

My Phone*

Fax

D.O.B

Age

Sex*

Tobacco*

Health Status*

If Yes, Please List Medications

Whole Life Death Benefit

UL Death Benefit

Term Death Benefit

Simplified Issue (Final Expense)

Comments

Group Health

Download the form below, or fill out form online!

Group Health Request Form

Group Health Quote Request Form

Legal Name of Business*

Full Business Address*

Legal Name of Business

Current Carrier Information (If plan is currently in force)

Upload

Current Effective Date (If applicable)

Requested Effective Date

Waiting Period

Number of Employees Currently Enrolled in Benefits

Total Number of FT Eligible Employees(W2)

Employee Only

Employee + Spouse

Employee + Children (ren)

Family

Number of Waivers (Valid Waivers Include: Spousal, Veterans, Medicare, Medicaid)

Employer Contribution %

Group Contact

Special Considerations*

Broker/Agency Name*

Phone*

E-mail*

Please note: Groups located outside NY must complete additional Employee Census

Disability

Long Term Care

On-Line and Request Forms for Download

Life Insurance

Group Health

Disability

Long Term Care