Life Insurance Quote

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Complete the details below to get your free life insurance quote

Quick Quote

* Indicates required field

Name *

First

Last

Please enter your first and last name

Address *

Line 1

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City

State

Zip Code

Country

Please enter your mailing address.

Email *

Please enter an email address we can use to contact you about this insurance quote.

Phone Number *

Please enter a phone number we can use to contact you about this insurance quote.

Coverage Type *

Please choose the type of life insurance coverage you're interested in.

Amount of Coverage *

Please enter the amount of coverage you'd like us to provide a quote for.

When would you like this policy to start? *

Please enter the date you’d like this new policy to go into effect.

Birthdate (MM/DD/YY) *

Please enter your date of birth in the following format: MM/DD/YYYY

Gender *

Please enter the gender of the person to be insured.

Height *

Please enter the height of the person to be insured.

Weight *

Please enter the weight of the person to be insured.

Tobacco Use? *

Does the person to be insured use tobacco?

Have you been diagnosed with any major illnesses in the past 10 years? *

Failure to disclose relevant information on a life insurance application can result in a denial of payment.

Do you have any relatives who have ever had heart disease? *

Failure to disclose relevant information on a life insurance application can result in a denial of payment.

Do you have any relatives who have ever had any form of cancer? *

Failure to disclose relevant information on a life insurance application can result in a denial of payment.

Do you engage in a hazardous hobby or occupation (e.g., rock climbing, private pilot, etc.)? *

Failure to disclose relevant information on a life insurance application can result in a denial of payment.

Additional Information: *

Please let us know if there's anything else we should know to provide you an accurate insurance quote.

🔒 Your information is secure.

Your private information is provided exclusively to our agency and will not be redistributed or sold to anyone else.

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Licensed in New York, New Jersey, Connecticut, Florida, Pennsylvania

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Allegiance Financial Group
421 7th Ave #900
New York, NY 10001
(212) 684-7444
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