Skip to content

Menu

Home
Our Mission
Our Team
Contact
Partner Login

Close Menu

Quote Request

Broker Information
Agent Name*
First Last
Company Name
Email*
Phone*
Client Information
Single Life or Joint Life*
Client's Name
First Last
Client's Date of Birth
MM slash DD slash YYYY
Client's Gender
Marital Status
Client's State
Client's Tobacco History
Assumed UW Class
Hidden
2 Clients Info
Client 1 Name
First Last
Client 1 Date of Birth
MM slash DD slash YYYY
Client 1 Gender
Client 1 State
Client 2 Name
First Last
Client 2 Date of Birth
MM slash DD slash YYYY
Client 2 Gender
Client 2 State
Primary objective
- Death Benefit
- Cash Accumulation
- Retirement Income
Other objectives / needs
- Key Man
- Family Protection
- Buy Sell
- Loan / Debt Repayment
- Other
Plan Type
- Term Life
- Universal Life
- Index UL
- Survivorship UL
- LTC
- LTC Hybrid
- Disability
- GUL
- Variable Life
- Whole Life
- Fixed Annuity
- Fixed Index Annuity
Complete for Life Quotes Only
Death Benefit
Term Life Duration
Permanent Life Premium Duration
Riders
Payment Mode
- Annual
- Semi-Annual
- Quarterly
- Monthly
1035 Exchange? (Yes/No)*
- Yes
- No
1035 Exchange or Non-1035 Lump Sum Amount
Death Benefit Option
- Level
- Increasing
Please provide current health status of insured or any additional pertinent information.
Complete for LTC/LTC Hybrid Quotes Only
Monthly Benefit Amount
Premium Duration
Elimination Period (If other than 90 days)
Benefit Period (If other than 5 years)
Complete for Disability Product Quotes Only
Monthly Benefit Amount
Insured's Occupation
Insured's Income
Additional Riders/Exclusions
Complete for Annuity Quote Only
Minimum Deposit Amount
Maximum Deposit Amount
Surrender Charge

Website is for agent use only. Not for use with the general public.

Securities and Investment Advisory Services offered through The Leaders Group, Inc. Securities Dealer, Member FINRA/SIPC; TLG Advisors, Inc. Registered Investment Advisors; 26 W. Dry Creek Circle, Suite 575, Littleton CO 80120, (303)797-9080. Element Insurance Partners is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: brokercheck.finra.org

My Cases

Our Mission
Our Team
Partner Login
Disclaimer

Element Insurance Partners
1406 Veterans Dr
Suite 102
Elkhorn, NE 68022
Phone: (402) 697-5074
Fax: 402-614-3990