Skip to main content
Group Life Quote 
Group Life Quote Request

Contact Information
Full Name:
Day Telephone:
Company Name:
Eve Telephone:
Street Address:
Fax:
City, State & Zip:
Best Time To Reach You:
E-Mail Address:
Current Insurance Information
If currently covered list carrier, # of years covered, and type of coverage
Employee Information
(If More Than 10 Employees, please call us to
receive a large group census form.)
List employees' required census data: (If More Than 10 Employees, place call us to
receive a large group census form.)
Employee #01 Status:
Age: Gender (M/F):
Employee #02 Status:
Age: Gender (M/F):
Employee #03 Status:
Age: Gender (M/F):
Employee #04 Status:
Age: Gender (M/F):
Employee #05 Status:
Age: Gender (M/F):
Employee #06 Status:
Age: Gender (M/F):
Employee #07 Status:
Age: Gender (M/F):
Employee #08 Status:
Age: Gender (M/F):
Employee #09 Status:
Age: Gender (M/F):
Employee #10 Status:
Age: Gender (M/F):
Coverage Information
Amount of Coverage Desired?
Type of Coverage? (Term, Universal life, Other):
TERM = Pays death benefit only - This is lowest cost for coverage.
UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit.
OTHER = Would be mortgage protection, whole life, etc.

Years of Level Premium:
Reason for Buying Life Insurance:
Any additional comments or information that might
be helpful in your quote

No coverage of any kind is bound or implied by submitting information via this online form

  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
Quick Quote Request 

    Carlton Risk Solutions LLC is licensed to provide insurance in NY & NJ Nikos Antivachis is licensed to provide insurance in NY, NJ, CA, FL, MI & NC
       

    © Carlton Risk Solutions, LLC, 2011 Powered By: Insurance Web Designs  webmail login