Dansard-Little Agency

Health/Life Quote

Life Insurance Information
Type
Amount of Death Benefit
Insured Information
Insured Name
Address
City
State
Zip
Home Phone
Email
Use Tobacco Yes  No
Gender Male  Female
Height
Weight
Insured Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Spouse Insurance Information
Spouse to be Insured? Yes  No
Spouse Use Tobacco? Yes  No
Gender Male  Female
Height
Weight
Children Yes  No
Spouse Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Children Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency Weekly  Monthly  Yearly
Other Disability Coverage? Yes  No
Other Disability Coverage Type Individual  Group
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD
Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
Send

logodlittlesail

 15621 S. Telegraph Rd
Monroe, MI 48161
phone: (734) 241-1133 
Fax: (734) 241-9275

Monday through Friday
8:30am-5:00pm
 
CLICK FOR A QUOTE

 








Facebook

Dansard-Little Insurance Facebook Page

Insurance News

Bender in California Names Guillen Vice President of Alternative Risk
Mon, 18 Jan 2021 06:00:14 +0000
Bender Insurance Solutions in Sacramento, Calif., has named Roland Guillen ...
Read More
Newfront in California Adds Parker as Employee Benefits Producer
Mon, 18 Jan 2021 06:00:01 +0000
Newfront Insurance in San Francisco, Calif., has brought Nichole Parker on ...
Read More
AXIS Capital Decides to Stop Insuring Arctic Oil and Gas Projects
Fri, 15 Jan 2021 17:37:10 +0000
AXIS Capital Holdings Ltd. said it won’t insure oil and gas projects in the...
Read More