* Required Information
About You
* Your First Name
* Last Name
* Email
* Email address (retype)
* Street Address
* City
*
* County
* Zip
* Phone (Day) Ext.
Phone (Evening)
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Your Life Insurance Information
Do you currently have Term Life Insurance? *
Yes
No
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
*
Are you a Male Female *
/    /    * What is your Birth Date (mm/dd/yyyy)
* Your Height
* Your Weight
*
*
*
Are you, your spouse or any dependents now pregnant? *
Yes No
Are you a citizen of the United States? *
Yes No
Have you lived outside the United States during the last 3 years? *
Yes No
Do you plan to leave the United States for travel or residence? *
Yes No
To your knowledge, is there any family history of cardiovascular disease before the age of 60? *
Yes No
Spouse? Include in Quote Don't Include
Spouse is aMale Female
/ / Spouse's Birth Date (mm/dd/yyyy)
Spouse's Height
Spouse's Weight
Details
When would you like to be contacted? *
Morning
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Any Time
 
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More Questions? Call (800) 279-2290

The Instant Term and Select Term life insurance policies are issued by The American Life Insurance Company of New York, a fully licensed, 50-state insurer, with its home office in New York, NY. American Life has a rating of Very Good (B++) from A.M. Best (on a scale of A++ to F) for financial strength and operating stability. The products are obligations of American Life, are not insured by the FDIC and are not guaranteed deposits. Life insurance policies contain exclusions and limitations; benefits may vary due to misstatement of age or sex. The products may not be available in all states. The policies are issued as ALNY-SEL-03 and ALNY-INST-03, respectively, or a variation of such. Shannon F. Kennedy, Licensed Agent. CA License # 0D43589

The term life insurance is issued by Guarantee Trust Life Insurance Company, home office in Glenview, IL. The product is an obligation of Guarantee Trust Life and is not insured by the FDIC and is not a guaranteed deposit. Life insurance policies contain exclusions and limitations; benefits may vary due to misstatement of age or sex. Product may not be available in all states. Forms: Policy Series 99RTNP; Group Master Policy LMP-2000.

Shannon Kennedy, Licensed Agent. CA License # 0D43589
 

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