New York Area Employee Life Insurance Plan Quote

**Information received from this NY, CT, or NJ Employee 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 employee life insurance plan 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 an Employee Life Insurance Plan Policy. We are licensed in New York, Connecticut,

and New Jersey, and will not provide quotes for other states.

We offer affordable employee life insurance plans for businesses 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.

Business Name:
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Group Term Life Insurance Objective:
Amount of Life Insurance Desired Per Employee:    Other Amount:$

How many employees to be insured:

Did any employee to be insured have health problems during
the past 18 months?
If "Yes", please list information below.

Does any employee to be insured have a hazardous job? Yes No
If Yes, how many have hazardous jobs?

Are any employees to be insured active members of the military reserves? Yes No
If Yes, how many are active members of the military reserves?

Additional Information or Comments

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

We also offer affordable employee life insurance plans for businesses 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.