Young Insurance would like to help you get started on the quote process. Below we are going to ask you a series of questions that will help guide us in providing you with the right information. So we encourage you to please answer these questions as completely as possible. We will ensure that your information remains private and confidential.

*=Required

*Your Name
Your Address
*Date of Birth
*Phone Number
Fax Number
*E-Mail Address
*Smoking Status (includes all types)	--Please Select-- I am a Smoker I am a Non-Smoker
Type Of Insurance Requested	--Please Select-- Term Life Whole Life Universal Life Mortgage Other
Other Insurance Requested	--Please Select-- Disability Critical Illness Travel Insurance Other
If Other:
Comments/Requests:
*Acknowledgement: (You accept this is only a request for quotation)	(Required)
*Security Code:

Please be advised that premiums quoted are not guaranteed and may be subject to additional medical underwriting.

Once submitted this form will generate an e-mail to you and to Young Insurance. If you find any of the submitted information is inaccurate, please let us know immediately.

Thank you for allowing us the chance to help you take care of your insurance needs.

---

If you have any questions or require more information,
please do not hesitate to contact us at 280-1470.