Life Insurance Quote

**Information received from this NY, CT, or NJ Life Insurance quote

request form sent to Direct Access Group Benefits will be for our use only

and will not be sold, given to or distributed to any other parties. A quote will be based

on the life insurance policy information provided and does not guarantee

acceptance of the risk by us. The precise coverage afforded is subject to meeting

underwriting guidelines, and the terms, conditions and exclusions of the policy as

issued. By submitting this request you acknowledge that this is neither an offer to

insure nor a guarantee of insurance. Completion of this form does not entitle you

to a Life Insurance Policy. We are licensed in New York, Connecticut, and New Jersey

and will not provide life insurance quotes for other states.

We offer affordable term life, universal life, and whole life insurance policy premiums in the
following New York counties and cities: Westchester County, Putnam County, Orange
County, Rockland County, Port Chester, Harrison, Mamaroneck, Larchmont, New Rochelle,
Yonkers, White Plains, Rye Brook, Scarsdale, Rye, Ardsley, Hartsdale, Bronxville, Mt.
Vernon, Mount Vernon, Irvington, Valhalla, Elmsford, Dobbs Ferry, Hastings on Hudson,
Greenburgh, Tarrytown, Sleepy Hollow, Hawthorne, Scarborough, Thornwood, Briarcliff
Manor, Ossining, Harmon, Montrose, Crugers, Buchanan, Peekskill, Millwood, Pleasantville
Armonk, Chappaqua, North Castle, Mt. Kisco, Bedford, Pound Ridge, Bedford Hills, Cross
River, South Salem, Yorktown Heights, Goldens Bridge, Amawalk, Yorktown, Katonah, Salem
Center, Somers, North Salem, Croton Falls, Jefferson Valley, Shrub Oak, Palisades, Sparkill,
Tappan, Orangeburg, Pearl River, West Nyack, New City, Nanuet, Chestnut Ridge,
Montebello, Suffern, Monsey, Spring Valley, Congers, Nyack, Rockland Lake, Wesley Hills,
New Hempstead, Pomona, Sloatsburg, Ramapo, Hilburn, Willow Grove, Mt. Ivy, Thiells,
Tomkins Cove, Ladentown, Haverstraw, Stony Point, Tomkins Cove, West Haverstraw, Bear
Mountain, Jones Point, Newburgh, Middletown, and Poughkeepsie, NY.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have life insurance?
Type of life insurance currently owned:
Current Premium:$ per month

Who will be insured:
Type of life insurance desired:
Amount of Life Insurance Desired:    Other Amount:$
Benefit Period Desired:

Has anyone to be insured had health problems during the past 2 years
or been diagnosed with a serious illness?
If "Yes", please list information below.

Does anyone to be insured have a hazardous job? Yes No
Is anyone to be insured an active member of the military reserves? Yes No

Additional Information or Comments

Click on the "Submit Quote Information" button below to
send your NY, CT, or NJ Life Insurance quote request.**

We also offer affordable whole life, term life, and universal life insurance policy premiums in the following
Connecticut counties and cities: Fairfield County, Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown,
Springdale, Round Hill, Old Greenwich, East Norwalk, New Canaan, Glenville, Byram, Cos Cob, Mianus, North
Stamford, Glenbrook, Wilton, Weston, Long Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport,
North Wilton, Winnipauk, Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown, Ridgefield,
Branchville, Redding, Topstone, Ridgebury, Redding Ridge, Branchville, Dodgingtown, West Redding, Titicus,
Hattertown, Bethel, Danbury, New Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney,
Shelton, Huntington, Upper Stepney, Long Hill, Trumbull, Stratford, Easton, Fairfield, Greenfield Hill, Stratfield,
Nichols, Oronoque, Rivercliff, Devon, Lordship, and East Bridgeport, and New Haven, CT.