Simplified Issue Proposal Request

SIMPLIFIED ISSUE LIFE INSURANCE

(Easy to Apply For)

Manhattan Life will issue Up to $100,000

Universal Life at Ages 18 to 80

No Blood, No Urine, No Medical Exam

Also available in: AZ AR CT DC DE IL GA MA
ME MS NC NH OH RI SC TN TX and WV
Applications for any of these states: Please call

Would you like a proposal?

Please complete the following short form and it will be sent to you promptly.

Broker Submitting Quote Request:
First Name:		City
Last Name:		State
Company:		Zip
Street Address 1:		Phone#:
Street Address 2:		Fax#:
		E-Mail:


Client Name:		Age:
DOB:		Smoker?
Sex:		State:
Height:		Weight:

Has your client ever been Rated or Declined for Insurance? If Yes, complete details please including Dates, Carrier, Offer.

Coverage Desired:

Death Benefit Desired


Please list All Medications being taken and dosage:


Does your client have any major health problems (example: cancer, etc.)?


Remarks: