Independent Life Agent

Thank you for your interest in contracting with our Company.

Our marketing structure is such that we do not contract agents or agencies directly, but rather through one of our existing and established Independent Marketing Organizations. Our primary focus and market niche is in simplified issue life products, predominately either final expense or term. Should you desire additional information about our products or contracting, please complete the Agent Form, and one of our IMO’s will contact you.

Name: Company Name: Address: City: State: Zip Code: Message:

I am interested in marketing the following products:

Final Expense Term Life Universal Life

Phone: Work Phone: Email: Website: Licensed States: How did you hear about us?

Check if you have ever contracted with any of our Companies If yes, provide agent number:

Check if you are an Individual Producer Check if you are an Agency If yes, how many agents do you have in your organization?