LA FAM

Life Insurance Intake

For Agents Only*
This form collects some basic information you’ll need ahead of time. It does not replace the application.

Download the PDF and save it to a secure location on your desktop.

The insured’s name, date of birth, and SSN are required. If the policy owner is different, their full name, date of birth, and SSN are also required. All other fields are optional. Answers stay in this page while it is open. Download your PDF before closing or refreshing.

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