J. Van Financial Group, PLLC.

Group Life Quote

Group Life Quote Request

Full Name:

Day Telephone:

Company Name:

Eve Telephone:

Street Address:

Fax:

City, State & Zip:

Best Time To Reach You:

E-Mail Address:

Current Insurance Information

If currently covered list carrier, # of years covered, and type of coverage

Employee Information
(If More Than 10 Employees, please call us to receive a large group census form.)

List employees' required census data: (If More Than 10 Employees, place call us to
receive a large group census form.)

Employee #01 Status:	Age: Gender (M/F):
Employee #02 Status:	Age: Gender (M/F):
Employee #03 Status:	Age: Gender (M/F):
Employee #04 Status:	Age: Gender (M/F):
Employee #05 Status:	Age: Gender (M/F):
Employee #06 Status:	Age: Gender (M/F):
Employee #07 Status:	Age: Gender (M/F):
Employee #08 Status:	Age: Gender (M/F):
Employee #09 Status:	Age: Gender (M/F):
Employee #10 Status:	Age: Gender (M/F):

Coverage Information:

Amount of Coverage Desired?
Type of Coverage? (Term, Universal life, Other):
TERM = Pays death benefit only - This is lowest cost for coverage. UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit. OTHER = Would be mortgage protection, whole life, etc.
Years of Level Premium:
Reason for Buying Life Insurance:

Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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Do I Need Life Insurance?

You need life insurance if anyone depends on your income. In such cases, life insurance solves many personal and business financial problems. Learn more about life insurance here.