Proposal Request - LifeStyle Insurance Services, Inc.

LifeStyle Insurance Services, Inc.
Proposal Request Form

Please fill out the form below to submit your Quote Request
Allow a 24-hour turnaround or call our office if needed sooner

Agent Name:		Date Needed:
Phone Number:		Fax Number:
License Number:		Email Address:

Choice of Carriers:

Please choose from the following: John Hancock, MetLife, Genworth, Prudential, UnumProvident, Prudential, Physicians Mutual and for declined cases only--Penn Treaty

Client Name:		DOB:
State of Residence:
Benefit Amount:
Benefit Duration:
Elimination Period:
Inflation:
Home Care %

Spouse/Partner:		DOB:
	If coverage desired, fill-in next 5 fields
Benefit Amount
Benefit Duration:
Elimination Period
Inflation:
Home Care %

Special Considerations:
Size of Estate, income or premium limit?

Medications:		Medications Spouse:

Please note in the field below:

Any serious illness, accident or hospitalization in last five years.
Requested riders (may include: indemnity, return of premium, full return of premium, HC Waiver, shared care, survivorship & waiver of premium, joint waiver of premium, restoration of benefits, home care plus, calendar day EP, rate guarantees and additional cash benefit.
If the spouse is a non-married partner.

This form is also available in Adobe Acrobat and Microsoft Word

Request for Proposal form in Adobe Request for Proposal form in Word

Carrier Underwriting Hotlines:

Genworth 800-354-6892
John Hancock 800-377-7311
MedAmerica 888-505-8952
MetLife 888-799-0902 #3
Prudential 800-800-8542
Physicians Mutual underwritinghotline@pmic.com
UnumProvident 888-278-1176