Personal Life Insurance Quotes

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have life insurance?
Type of life insurance currently owned:
Current Premium:$ per month

Life Insurance Coverage Information:

Who will be insured:
Type of life insurance desired:
Amount of Life Insurance Desired:    Other Amount:$
Benefit Period Desired:

Has anyone to be insured had health problems during the past 2 years
or been diagnosed with a serious illness?
If "Yes", please list information below.

Does anyone to be insured have a hazardous job? Yes No
Is anyone to be insured an active member of the military reserves? Yes No

Additional Information or Comments

Click on the "Submit Quote Information" button
below to send your Life Insurance quote request.**

**Information received from this Life Insurance quote request form sent to
Insurance Plus will be for our use only and will not be sold, given to or
distributed to any other parties. A quote will be based on the life insurance
policy information provided and does not guarantee acceptance of the risk
by us. The precise coverage afforded is subject to meeting underwriting
guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an
offer to insure nor a guarantee of insurance. Completion of this form does
not entitle you to a Life Insurance Policy. We are licensed in New York
and will not provide life insurance quotes for other states.

We are your local Long Island, NY insurance agency, offering affordable
Life Insurance policy premiums in the following New York City area cities
and counties: Oyster Bay, Huntington, Glen Cove, Port Washington, Roslyn,
Syosset, Jericho, East Hills, Great Neck, South Huntington, Melville,
Pinelawn, Farmingdale, Bethpage, Levittown, Lindenhurst, Babylon, Bay
Shore, Islip, Northport, Hicksville, Westbury, Mineola, Garden City, Long
Island City, Manhasset, Massapequa, Freeport, Lynbrook, Rockville Centre,
Hempstead, Elmont, Valley Stream, Long Beach, Oceanside, Amityville,
Merrick, Bellmore, Jamaica, Brooklyn, Bronx, Flatbush, Queens, Astoria,
Cove Neck, Bayville, Locust Valley, Lattingtown, Matinecock, Mill Neck, Sea
Cliff, Centre Island, Brookville, Locust Grove, Muttontown, East Norwich,
Old Westbury, North Massapequa, Seaford, Manorhaven, Huntington Station,
Huntington Bay, Greenlawn, Commack, Plainview, Deer Park, Farmingdale,
West Babylon, Brentwood, Central Islip, East Northport, Centereach, Coram,
Riverhead, Lido Beach, New Suffolk, Port Jefferson, and everywhere else in
Nassau County, Queens County, Kings County, New York County, Bronx
County, Westchester County, and Suffolk County, NY.