StarLife Partners A Wholesale Insurance Brokerage

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Our Affiliated Carriers

please complete this form to obtain the best quote possible for your client. Our staff of experts will return your quote within 2 business hours.
	*Fields marked with are required**
Producer:
*Agent Name:
*Address:
*City:
*State:
*Zip:
*Email Address:
*Phone #:
Fax #:
Return Method:	Fax Mail Broker Pick-up Email

Client info:

Name:
Birthdate:	or age Gender: Male Female
Health Class:	Super Preferred Preferred Standard Sub-Standard
Tobacco Use:	Pipe Cigar Chewing Cigarettes
Medical Problems:	Are you aware of any condition which may impact your clients underwriting, if yes click here
Illustration:
Primary Objective:
Death Benefit Cash Accumulation Guarantees Low Premium
Face Amount(s):	Specified Carrier:

Product Type:
Universal Life Whole Life Whole Life Blend% Term Variable Survivorship
Term: ART 5 10 15 20 30 Other

Years to pay:
-Pay -To Year To Age
1035 Rollover: Dump-In:
Cash Value Target:
Amount: at Maturity or Age
Payment Mode:
Annual Semi-Annual Quarterly Monthly
State of Issue:
State in which insurance is to be issued -
Riders:
Term Rider - Insured Amount: To Age:
Waiver of Premium
Child Insurance Rider:
ADB:
Other:
Please use field below to describe any specific instructions :

Supplies:
Appointment Package Application Package Product Details
Your request cannot be honored unless this form is completed.

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.