Insurance Center Of The Southeast

Health/Life Quote

Life Insurance Information
Type
Amount of Death Benefit
Insured Information
Insured Name
Address
City
State
Zip
Home Phone
Email
Use Tobacco Yes  No
Gender Male  Female
Height
Weight
Insured Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Spouse Insurance Information
Spouse to be Insured? Yes  No
Spouse Use Tobacco? Yes  No
Gender Male  Female
Height
Weight
Children Yes  No
Spouse Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Children Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency Weekly  Monthly  Yearly
Other Disability Coverage? Yes  No
Other Disability Coverage Type Individual  Group
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD

Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

1296 Westgate Parkway
Dothan AL 36303
(334) 793-0014


ContactUs

Like Us on Facebook




Insurance News

Tue, 26 Oct 2021 23:18:26 +0000
It’s part of just about every cannabis conversation: “Hey, it looks like we...
Tue, 26 Oct 2021 21:27:18 +0000
The California Labor Commissioner’s Office cited Bodega Latina (dba El Supe...
Tue, 26 Oct 2021 16:41:49 +0000
The Texas Windstorm Insurance Association expects policies in-force to incr...