Toll Free 866-589-1901
Agent Resources, Inc.
  • Home
  • Life
  • SENIOR LIFE
  • Long Term Care
  • Disability
  • Annuities
  • Life Settlements
  • Medicare Supplement
  • Critical Illness
  • Applications
  • Travel & Int'l Health Ins
  • Resources/Tools
  • Secure File Upload
  • Contracting
  • Contact Us

    Agent Resources Inc.
    EZ-App

    Do Not Use This Process If an Exam is not required or the Owner is other than the Insured.

    Agent Contact Info



    Beneficiary Information


    Policy Information


    Existing Insurance

    If Yes to either answer above please complete the info below:

    General Questions

    If you answer "Yes" to any questions please provide details in remarks.
    ​

    Foreign Travel / Hazardous Avocation
    ​

    Include activity, how often, how long participating and any certifications.
    provide dates, violations and any court ordered penalization.
    By Clicking the I AGREE check box below, I state the following:

    1)-I am a duly licensed and appointed (if pre-appointment is required) life insurance agent in the State in which the proposed insured was solicited and in the State in which the policy, if one is issued, will be delivered. 2)-The plan and amount or insurance identified is suitable in view of the owners insurance needs and financial objectives. 3)-The information provided is complete, accurate and correctly recorded, and 4)-all required forms have been provided to the applicant.

    I Authorize Agent Resources Inc. and/or its fulfillment center representative to obtain such administrative information as may be necessary to complete any life insurance resulting from this lead submission, provided, however that any item of information or question from owner or proposed nsured requiring the act or advice of a licensed life insurance agent will be referred to me for action before the application can be completed.

    I will personally review the application created form this data and administrative information provided by the proposed insured and contact him or her concerning any incomplete or inconsistent information and I will not deliver the policy unless I have completed my review and am satisfied that the policy, application and all attached papers, if any are complete and accurate.

    All forms required to be delivered at the time of solicitation have been delivered and all other forms (including privacy notice, if necessary) required have been or will be provided to the applicant.

    I acknowledge that clicking the "I Agree" and "SUBMIT" Button below constitutes my signature on the form and has the same effect as if I personally signed the form.
Submit
Home  |   Life  |   LTC  |  Disability  |  Annuities  |  Applications/Forms  |  Contracting  |  Contact US  |  Resources
This site is intended for Agent/Broker use only
If you are a consumer interested in purchasing insurance click below
​
Consumer Site
Site powered by IXN Tech