WorkingAmericanBenefits™

                                                                     
Product Selection:

 Life Insurance                                                  Company                                   Amt. of Insurance

    Term Life Insurance              Select ALLIANZ Life Insurance Company Allstate Financial - AH Life Ins.Co. Colonial Supplemental Insurance Colorado Bankers Life Insurance Co. Illinois Mutual Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Whole Life Insurance            Select ALLIANZ Life Insurance Company Colorado Bankers Life Insurance Co. Illinois Mutual Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Universal Life Insurance          Select ALLIANZ Life Insurance Company Allstate Financial - AH Life Ins.Co. Colonial Supplemental Insurance Illinois Mutual Life Insurance Co. Texas Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Indexed Universal Life Ins.     Select Allianz Life Insurance Co. of No. America Life Insurance Company of the Southwest AVIVA/Indianapolis Life Insurance Company    

 Gap/Bridge Ins.                                                Company                                  Amt. of Insurance

    Hospital Indemnity Ins.          Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Fidelity Security Insurance Company       

 Dread Disease Ins.                                          Company                                  Amt./Plan of Ins.

    Cancer Insurance                  Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance ING - Relia Star Insurance Company       

    Critical Illness Insurance       Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Colorado Bankers Life Insurance Co. Fort Dearborn Life Insurance Co. ING - Relia Star Insurance Company       

    Note: For Cancer coverage, enter the Plan of Insurance if the amount of insurance is not known.

 Disability Insurance                                        Company                                   Monthly Benefit

    Short Term Disability            Select Allstate Financial --- Amercan Heritage Life AIG - Professional Insurance Company Fort Dearborn Life Insurance Co. Illinois Mutual Life Insurance Co. ING - Relia Star Life Insurance Co. UnumProvident Life Insurance Co.      

    Long Term Disability          Select Fort Dearborn Life Insurance Company Illinois Mutual Life Insurance Company ING - Relia Star Life Insurance Company UnumProvident Life Insurance Company ____________________________________       

 Long Term Care Ins.                                       Company                                   Daily Benefit Amt.

    Long Term Care                    Select ALLIANZ Life Insurance Company CNA Life Insurance Company GE Capital Assurance Company Great American Life Insurance Company John Hancock Life Insurance Company Kanawha Insurance Company Physicians Mutual Insurance Company State Life Insurance Company UnumProvident Life Insurance Company ____________________________________       

 Legal Insurance                                               Company                                   Plan of Insurance

    Individual Legal Plan            Select U.S. Legal Services, Inc. ____________________________________        Select CDL Tax Watch Family Protector Business Protector Platinum Plus Protector

Person to be insured Information: 

Note: Enter all that applies.

Proposed Insured: (Required)

First Name:       *          MI:            Last Name:*    

Street Address *     Apt. or Suite No.:     

City:                    *            State: *  - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code: * 

Relationship:    * Select Self/Employee Spouse Dependent Other   Date Of Birth:* Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1045 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920   Male   Female

Height:            * ft ins  Weight:* lbs. E-mail Address:*   

Nicotine and Medication History: (Required)

01.  Have you or any person to be insured used any form of tobacco, or any nicotine products

       in the last 12 months?                                                                                                      Yes No

02.  Please list all medications you or any person to be insured take, the strength and the

       dosage of the medication in the space below.

IMPORTANT!                IMPORTANT!

If you were told about this website by an agent, please enter the agent's name and agent number (If known) in the space below.  This information may be found on the agent's business card or on a flyer or correspondence given to you by the agent:

Agent's Name:        Agent Number: 

Congratulations!  You have now completed your request for a quote.  Please click on  the SUBMIT button below to submit your request for processing.   Please check your e-mail at the e-mail address you provided above for  your quote.    If you do not receive your quote within a reasonable period of time, please call (954)430-8475 or send us an e-mail at customer_service@workingamericanbenefits.com.