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info@allchoiceinsurance.com
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Carrier Partners
GET A QUOTE
844.540.0463
Erie Express Life Insurance Quote Form
ALLCHOICE Agent Information
Select Your Advisor
*
Paul Shockley
Cheyenne Mathews
Sara Surigao
John Surigao
Heather Bailey
AJ Brower
Michael Reese
Ed Johnson
Bill Heasley
Jeff Hall
Jared Bellmund
INSURED INFORMATION
Proposed Insured
*
First
Last
Maiden (If Applicable)
Date Of Birth
MM slash DD slash YYYY
Gender
Female
Male
Hidden
Social Security Number
Height
Weight
CONTACT INFORMATION
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
No. of Years at this address?
Email
Mobile Phone
Best Time To Call
Birth Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
State of Birth
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Marital Status
Married
Single
Divorced
Widowed
Hidden
Do you authorize the release of the health related information to your Erie Family Life Agent?
Yes
No
How Long Have You Been Licensed? (and in which Sate)
Is the Proposed Insured currently employed?
Yes
No
Employer Name
Hidden
Employer Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hidden
Occupation
Hidden
Duties
No. of Years at Employer
Hidden
Employer Phone
BENEFICIARIES
Primary Beneficiary
First
Last
Hidden
Beneficiary Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Relation To Insured
Beneficiary Date Of Birth
MM slash DD slash YYYY
Hidden
Beneficiary Social (if you have it)
Hidden
Beneficiary Notes
State if more than 1 Beneficiary or if you want to include Contingent Beneficiary (complete the form then discuss with your agent)
PLAN INFORMATION
Proposed Insured Face Amount (Death Benefit)
Maximum Amount Of Coverage is $500,000
Premium Mode
*
SELECT PAY PLAN
Monthly EFT
Annual EFT
Annual - Bill
Send Premium Notices to:
Insured's Address
Other Address
Other Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
BANK INFORMATION
**Please Note - If You Select Monthly EFT we MUST have your routing and account number. If you do not enter that information, we will change the pay mode to Quarterly and we will have to amend the policy at the time of issue
Name on Account
Name of Bank
Type Of Account
Checking
Savings
Account Number
Routing Number
I authorize the Life Insurance Carrier to debit all initial premium required to place this policy active. I understand that the debit for the initial premium will occur upon policy issue and receipt of all applicable delivery requirements.
Yes
No
EXPRESS UNDERWRITING QUESTIONS
Tobacco Usage
*
Never Used
Past User - Quit Over 24 Months Ago
Current User (or quit within last 24 months)
Are you a member or have you entered into a written agreement to become a member of the United States Armed Forces?
*
No
Yes
In the past 10 years, have you used any controlled substance (other than marijuana) such as cocaine, heroin, opioids, narcotics, barbiturates, amphetamines, sedatives or hallucinogens without a medical prescription?
*
No
Yes
Have you ever been convicted of or pled guilty or no contest to any felony or are you currently under indictment, awaiting trial or sentencing, or on probation or parole?
*
No
Yes
In the past 5 years, have you ever had or been advised by a member of the medical profession to have a kidney, liver, heart or other internal organ transplant?
*
No
Yes
Have you ever been diagnosed with, treated, tested positive for, or been given medical advice by a member of the medical profession for:
*
**CHECK ALL THAT APPLY**
NONE OF THESE APPLY
Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?
Any disease or disorder of the heart including, but not limited to: coronary artery disease, heart attack, coronary artery bypass, angioplasty or stents, heart valve disorder or surgery?
Any disease or disorder of the brain or nervous system including, but not limited to: multiple sclerosis, Parkinson's disease, stroke or transient ischemic attack (TIA), aneurysm, muscular dystrophy, ALS (Lou Gehrig's disease), or paralysis?
Any cancer (other than non-melanoma skin cancer) including, but not limited to: malignant tumors, lymphoma, Hodgkin's disease, leukemia, or melanoma?
Diabetes, kidney disease or disorder, hepatitis B or C, fibrosis or cirrhosis of the liver?
Any disease requiring the use of oxygen including, but not limited to: emphysema or chronic obstructive pulmonary disease (COPD)?
Bi-polar disorder, schizophrenia, psychosis, suicide attempt or post-traumatic stress disorder (PTSD)?
In the past 2 years, have you been hospitalized for any reason (other than pregnancy and normal delivery)?
PRIMARY PHYSICIAN
Do You Have A Primary Physician?
*
No
Yes
Physician Name, or Practice Name, or None
Physican | Practice Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physician | Practice Phone
Date Last Seen (approx if you don't know)
Reason for visit, findings, treatment (if any)
Δ
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