Assurity Accidental Death Contracting Request

Have you presented this guaranteed issue accidental death product/illustration to your client?*

Yes
No

(Please present options to the client before proceeding with contracting. PLEASE only proceed with contracting if your client is ready to purchase.)

Can you confirm if your client is above the age of 18 and below age 70?*

Yes
No

You are unable to submit an e-application with the carrier due to client age restrictions. Therefore, we cannot complete the contracting request for this carrier.

Did your client agree to purchase the product and are they ready to submit an application to the carrier?*

Yes
No

In order to proceed with contracting, your client has to agree to purchase the policy. If we get you contracted with the carrier and you do not submit an application in the first 30 days, the carrier will cancel your contract and we will have to go back through contracting again later. PLEASE only proceed with contracting if your client is ready to purchase.

Have you been contracted with this carrier under OCI?*

Yes
No

Please follow the instructions below to set up your Assurity Account and Submit your E-Application.

Assurity Account Set Up Link

Account Set-Up Instructions:
• Create an Account (Make sure that the “Account Type” is marked Agent Account)
• Agent ID: Assurity Writing Number (This will come from Assurity in an email)

Once your Assurity account has been set up click the link below to submit the formal application for your client.

Accidental Death E-Application Link

*A quote will need to be re-ran in order to start the application*

Agent Name:*

First Last

Are you the agency owner?*

Yes
No

Agent Company:*

Agent Email:*

Agent Phone:*

Client's Name:*

First Last

Client's Date of Birth:*

Coverage Amount:*

State:*

State

Coverage Amount:*

PLEASE CONFIRM: Due to the internal cost and time needed for contracting, do you pinky promise that your client will move forward with purchasing the policy?*

Yes
No

CAPTCHA