Applying for Term Life Insurance
 
Applicant Full Name:
     Birth Date (mm/dd/yyyy):    Gender: 
Social Security/Tax Number:
Mailing Address:
City:
     State:    Zipcode: 
Phones:
 Home Phone:     Work Phone:     Cell Phone: 
         Best Phone to Contact:  Home /  Work /  Cell     Best Time to Call: 
E-Mail Address:
Occupation:
    ANY Tobacco Use?  Yes  /  No

POLICY TYPE
Type of Term Requested: 10 Year Level Premium 15 Year Level Premium 20 Year Level Premium 30 Year Level Premium Death Benefit
$ 
Policy Riders: Waiver of Premium Accidental Death Benefit Children's Insurance Rider    
Units
($ 1,000 per unit)		    

BENEFICIARIES
Primary Beneficiary Relationship % of Death Benefit Birth Date
Name 1:  %
Name 2:  %
Contingent Beneficiary (if the primary beneficiary(s) predecease the insured) Relationship % of Death Benefit Birth Date
Name 1: 
   or "All children of the insured and the Primary Beneficiary (equal shares): 		 %
Name 2:  %

SUBMISSION
Once you submit the request to us, we will:
     
  • Submit the information to the insurance
  • Set up the medical exam
  • The insurance company will handle the application process

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474     Fax: (724) 327-7911
Toll Free: 1-800-977-2999