GHM Insurance Agency

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Life Insurance Quote Form

Note: Offer only pertains to residents of Maine or anyone relocating to Maine

Please fill out the following form, and then click on the "Submit Request" button. Your request will be processed and you will receive a quote soon.

Applicant Info

Name:
Your email address:
Mailing Address:
City:
State:
Zip Code:
Phone #:
Actual address (if different from mailing address):

Do you have Life Insurance now?	yes no
If so, what company issued the contract?
What age were you when the contract was issued?
What is the face amount of the contract?
What type of contract is it? (Term, whole life, universal, variable, etc.)
What premium are you paying now?

What is your date of birth?

Please list dates of birth for your spouse and children:

Do you use tobacco in any form?	yes no
If so, what form?
What is your general health?
What is your occupation?
What type of contract are you interested in?
If Term Life, how many years do you want the contract?
What amount of insurance are you interested in?
What date would you like the policy to be written?
What type of premium are you interested in?

Please explain briefly your reason for purchasing this insurance:

Do you have a pension plan? yes no
I would like to receive my quote by:
What is the best time to contact you by phone?
Aything else we may need to know?

© GHM Agency 2004

Disclaimer: Please be advised that no insurance can be purchased, bound, or put into effect over the GHM Agency website. To start a policy or make changes to an existing policy, you must first speak with a GHM agent who will assist you accordingly. Thank You.