Al Shank Insurance - Life Insurance Quote Form

Please complete this form and select the SUBMIT button at the bottom of the page.

You will receive your free life insurance quote within three working days.

Information provided will be kept confidential and used for quoting purposes only. All quotes are based on the information given and are subject to change upon further inspection. Coverage can not be bound via e-mail or internet service.

Applicant Information

Name:
Street Address:
City:	State: ZIP:
County:
E-Mail Address:	Fax: () -
Home Phone:	() - Work Phone: () -

Coverage Information - Applicant #1

Name:
Age:		Gender:	Male Female
Height:		Weight:
Occupation:		Do you smoke?	Yes No
Type of Policy Desired:	Term Insurance Whole Life Insurance Term Insurance: Term insurance is temporary. The death benefit of a term life insurance policy is payable to the beneficiary at the death of the insured, provided death occurs with a period (i.e. 1,5,10 years) specified by the policy. Whole Life Insurance: The death benefit of whole life insurance is payable to the beneficiary at the death of the insured whenever that occurs provided the insured is less than age 100. Premiums may be payable for a specified number of years or for life. Amount of Coverage Specified period (term in years) of protection (for term insurance only)
Purpose(s) of this Life Insurance Policy:	Mortgage Protection - Pay off the remaining mortgage on your home. Final Expenses - Funeral Home and Burial Costs. Family Income - Compensate survivors for loss of income. College Fund Estate Liquidity Retirement (savings)

Coverage Information - Applicant #2

Name:
Age:		Gender:	Male Female
Height:		Weight:
Occupation:		Do you smoke?	Yes No
Type of Policy Desired:	Term Insurance Whole Life Insurance Term Insurance: Term insurance is temporary. The death benefit of a term life insurance policy is payable to the beneficiary at the death of the insured, provided death occurs with a period (i.e. 1,5,10 years) specified by the policy. Whole Life Insurance: The death benefit of whole life insurance is payable to the beneficiary at the death of the insured whenever that occurs provided the insured is less than age 100. Premiums may be payable for a specified number of years or for life. Amount of Coverage Specified period (term in years) of protection (for term insurance only)
Purpose(s) of this Life Insurance Policy:	Mortgage Protection - Pay off the remaining mortgage on your home. Final Expenses - Funeral Home and Burial Costs. Family Income - Compensate survivors for loss of income. College Fund Estate Liquidity Retirement (savings)

Thank you for asking us to quote your insurance coverage!