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E-Mail:
info@fivestar
insuranceagency.com

Toll-Free Phone:
1-866-740-4132

Local Phone:
1-678-526-7979

Fax Number:
1-678-526-7222

Office Address:
2093 Rock Chapel Road
Lithonia, GA 30058

Five Star Insurance Agency

Owned and Operated by:
Aisha Smith-Danzy
Since 2006

Proudly Representing:

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Ins. Web Sales, Inc.


Georgia insurance quote

 
On-Line Life Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data:
 
Your Name:
Street Address:
City:
State:
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Are You Married?
Yes No
Currently Insured?
Yes No
 
If currently covered list carrier, # of years covered, and type of coverage
 
Unusual Activities?
(If you engage in unusual activities such as scuba diving, airplane flying, rock climbing, etc., list them here.)

Underwriting Information:
 
Name of Proposed Insured:
Enter Proposed Insured's Birthdate:  
Sex (M/F): Do You Smoke?:
Height: Weight:
Spouse's Information:
(Leave Blank if you do NOT want Spouse Coverage)
 
Name of Spouse:
Enter Spouse's Birthdate:  
Sex (M/F): Do You Smoke?:
Spouse Height: Spouse Weight:


Coverages:

Amount of Coverage Desired?
 
Type of Life Coverage Desired?
 
TERM = Pays death benefit only - This is lowest cost for coverage.
UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit.
 OTHER = Would be mortgage protection, whole life, no-exam life, etc.
 
Years of Level Premium, if selecting term life.
 
List Any Health Problems:
 
Reason for Buying Life Insurance:
 
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