StarLife Partners A Wholesale Insurance Brokerage

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Fill in the form below to receive a Disability Illustration:
All Fields Are Required
Agent Information
Agent's Name:
Phone #: :		Fax #:
Date:
Client Information
Client's Name:
Date of Birth:
Sex:	Male Female
State:
Tobacco:	Yes No
Job Title and Duties:
Annual Income + any bonuses:
Business Owner?:	Yes No
	If Yes, Years of Ownership:
	# of Fulltime Employees:
Existing Coverage:	Individual: Group:
	Elimination Period: Benefit Period:
Plan Design Information
Plan Type: Personal Business Overhead Buy/Sell
Elimination Period
Personal:
Business Overhead:
Buy/Sell
Benefit Period
Personal:
Business Overhead:
Buy/Sell
Monthly Benefit
Desired Amount:
Quote Maximum:
Optional Benefits
Cola %:
Other:
Additional Information: Please indicate any special health/underwriting considerations. A disability illustration cannot be provided unless this form is completely filled out.

StarLife Partners is currently licensed in the State of New York The StarLife Partners web site is maintained exclusively for active producers contracted with carriers through StarLife Partners, and is intended for agent use only. All information is intended for use as a guide, or as reference, and is believed to be current as of the date of its posting. Any misrepresentation of the information contained in the StarLife Partners web site by its users is strictly prohibited.

The list of registered StarLife Partners web site users is reviewed for business-related activity on a regular basis. Only registered users will
receive site support of any kind. Comments and suggestions are encouraged.