Applicant Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:


Currently Insured:



Life Insurance Information

Date of Birth:

Gender:

Height:

Weight:


Do You Smoke:


Currently Own Life Insurance:


Type of Life Insurance Owned:


Current Premium (monthly):
$

Who Will Be Insured:



Coverage Information

Type of Life Insurance Desired:


Amount of Life Insurance Desired:


Other Insurance Amount Desired:


Benefit Period Desired:



Has anyone to be insured had
health problems during the past
10 years or diagnosed with a
serious illness:


If Yes, list information:


Anyone to be insured
have a hazardous job:


Anyone to be insured an active
member of the military reserves:



Question or Message:




Click the "Submit Quote Request"
button below to send your New York
Life Insurance request to
Direct Access Group Benefits.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Somers, NY insurance
agency offering affordable New York
life insurance quotes in the
following towns, cities and counties
in the Westchester County, NY area:
Port Chester, Harrison, Mamaroneck,
Larchmont, New Rochelle, Yonkers,
White Plains, Rye Brook, Scarsdale,
Rye, Ardsley, Hartsdale, Bronxville,
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, Bronx,
New York City, Brewster, Poughkeepsie,
Putnam County, Orange County, and
Rockland County, New York.
Life Insurance Quote
Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved
914-276-6000
800-498-1819
Westchester County New York Insurance Agency