Proposed Policy Information

Insured Info

Age

Gender

Height Feet / Inches

/

Weight

Tobacco

Family History (100 character max)

Policy Info

Face Amount

Insured Information (Limit 5)

Concern #1

Type of Concern

Diagnosis (50 character max)

Age at Onset

Treatment (50 character max)

Path Report: Microscopic Description (Cancer only)

Other Information (Limit 700 characters)

Concern #2

Type of Concern

Diagnosis (50 character max)

Age at Onset

Treatment (50 character max)

Path Report: Microscopic Description (Cancer only)

Other Information (Limit 700 characters)

Concern #3

Type of Concern

Diagnosis (50 character max)

Age at Onset

Treatment (50 character max)

Path Report: Microscopic Description (Cancer only)

Other Information (Limit 700 characters)

Concern #4

Type of Concern

Diagnosis (50 character max)

Age at Onset

Treatment (50 character max)

Path Report: Microscopic Description (Cancer only)

Other Information (Limit 700 characters)

Concern #5

Type of Concern

Diagnosis (50 character max)

Age at Onset

Treatment (50 character max)

Path Report: Microscopic Description (Cancer only)

Other Information (Limit 700 characters)

Agency Information

Contact Info

Name

Agency

Phone Number

Extension

Email

QuickQuote Reference

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Other Carriers (Max 3)

Carrier Email

Carrier #1 Email

Carrier #2 Email

Carrier #3 Email



  By checking this box I accept the QuickQuote terms and conditions:

Legal & General America will do its best to issue a policy that matches the tentative offer you’ll receive in response to this request. The QuickQuote will be non-binding and based solely on the information you have provided above. A final decision will be made after receipt, review and assessment of a formal application, age and amount requirements, any interim Attending Physician Statement(s), and any required facultative reinsurance review. Our formal review and risk assessment will include review of Medical Information Bureau and Motor Vehicle Record reports, identity verification, no finding suggestive of a hereditary cancer syndrome, and financial documentation necessary to justify in force and applied for coverage. The QuickQuote will be valid for 60 days from the date of the response and a copy of the QuickQuote must accompany the formal application.

Legal & General America life insurance products are underwritten and issued by Banner Life Insurance Company, Urbana, MD and William Penn Life Insurance Company of New York, Garden City, NY. Banner products are distributed in 49 states and in DC. Banner does not solicit business in NY.