Applicant Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:
Select One Cell Phone Daytime Phone Email

Currently Insured:
Select One Yes No


Life Insurance Information

Date of Birth:

Gender:
Select One Female Male
Height:

Weight:


Do You Smoke:
Select One Yes No

Currently Own Life Insurance:
Select One Yes No

Type of Life Insurance Owned:


Current Premium (monthly):
$

Who Will Be Insured:
Select One Applicant Only Spouse Only Child Only Other


Coverage Information

Type of Life Insurance Desired:
Select One Term Life Whole Life Universal Life Other

Amount of Life Insurance Desired:
Select One $100,000 $150,000 $200,000 $250,000 $500,000 $1 million Other Amount

Other Insurance Amount Desired:


Benefit Period Desired:
Select One 10 years (Term Life) 15 years (Term Life) 20 years (Term Life) 30 years (Term Life) 10 years (Universal Life) 15 years (Universal Life) 20 years (Universal Life) 30 years (Universal Life) To Age 100 (Universal Life) 10 years (Whole Life) 15 years (Whole Life) 20 years (Whole Life) 30 years (Whole Life)


Has anyone to be insured had
health problems during the past
10 years or diagnosed with a
serious illness:
Select One Yes No

If Yes, list information:


Anyone to be insured
have a hazardous job:
Select One Yes No

Anyone to be insured an active
member of the military reserves:
Select One Yes No


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.



Direct Access Group Benefits, Inc.
189 Route 100, PO Box 590
Somers, New York 10589
Westchester County, New York

Life Insurance Quote

Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved