Life Insurance Leads and Top Commissions


Monday, May 12, 2008		Request a Quote

Quote Form

Have a case you’re working on?
Complete the information below to get a quote.
We will contact you within 24 hours!

Required fields to submit the form are indicated by *.

Client Profile

First Name:*

Last Name:*

State:*

Date of Birth:*

Tobacco:

Non Preferred
If preferred is not checked, standard will be assumed

Face Amount:*

Plan Type:

UL Term Years

Term Years:

Current Plan:

Current Premium:

Surrender Value/
1035 Exchange Amount
if applicable:*

Agent Profile

Date:*

First Name:*

Last Name:*

Agency Name:

Street Address:*

City:*

State:*

Zip Code:*

Phone Number:*

Fax Number:

Email Address:*

Lead Programs:*
(check all that apply)

Life: Annuity: Seminar System:

LTC: Final Expense:

Company's Info Requested:*
(check all that apply)

Allianz
American General
American National
AmerUS Annuity
Chesapeake Life
Empire General
F&G Life
Guaranteed Issue
Impaired Risk Company
Indianapolis Life
ING USA Annuity
Midland National
People's Benefit Life
Shenandoah Life
West Coast Life
Other

Current Market Information

Please complete the following information regarding your current work.

Current Market

Market Niche:*

Premium Production:*

Current Company:*

Current Commission Level:*

LifeCo Insurance Marketing 7400 E. Caley Avenue Suite 170 Englewood, Colorado 80111
303.224.0788 800.234.1480 Fax: 303.224.0789