LRC and Associates
1-800-443-5149
Under Construction
Universal Life Quote Request Page
* Required fields
Name *
E-mail Address *
Prospects Name
State of Residence *
NY
- - -
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Prospects Age (nearestbirthday) or DOB
Tobacco Use in last 12 months *
No
Yes
Rate Class to Quote
Best Preferred Rate
2nd Best Preferred Rate
Standard Rate
Sub-Standard Rate
Preferred Smoker
Standard Smoker
Illustrate Spouse With Same Benefits
Yes
No: (Fill out seperate quote request and Submit)
Spouse's Name
Spouse's Date of Birth (or age nearest birthday)
Spouse's Rate Class to Quote
Best Preferred Rate
2nd Best Preferred Rate
Standard Rate
Sub-Standard Rate
Preferred Smoker
Standard Smoker
Banner Life (Non-NY)
Companion Life
John Hancock
United World (Mutual of Omaha Non-NY)
William Penn
Face Amount
Death Benefit Option
Level
Increasing
Premium Mode
Annual
Semi-Annual
Quarterly
Monthly (Check-O-Matic)
Premium Payment Option
Minimum (Base)
Target
Solve
Solve for Premium Options
Sinlge Pay
10 Pay
20 Pay
Pay to age 65
Pay to age 100
Pay for ever
Other (see next choice)
Other Premium Option to Solve for
Cash Value Solve Options
Zero CV at age 100
Endow at age 100
Other (see next option)
Other Cash Value Option to Solve for
Additional Info./Health Conditions/Medications/Notes
What should we do with your quote?
E-mail Full Proposal
Fax Full Proposal
E-mail Page One Only
Fax Page One Only
Mail Full Proposal
Need An Application?
No
Yes-Email
Yes-Snail Mail
Address
Phone
Fax
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