CALL US AT

(855) 468-8900

CALL US AT

(855) 468-8900

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AIG Guaranteed Acceptance Pre App

Hassan Sanders

CEO/National Independent Agent

National Producer Number: 12878572

Toll-Free: (855) 468-8900

Direct: (855) 468-8900

Fax: (888)-506-1532

Email: [email protected]

Website: www.BestBurialPolicy.com

Full Legal Name *

Email *

Phone Number *

Full Address *

Date of Birth (mm/dd/yyyy) *

Social Security Number *

Gender *

Male

Female

State of Birth *

Coverage Amount *

Payment *

Checking

Savings

Are you a United States Citizen or do you have Permanent Legal Resident (Green Card) status? *

Yes

No

Beneficiary Information (Full Name/Relationship to insured) Date Of Birth *

Do you have any existing annuity or life insurance or have any application pending for such coverage with this Company or any other company? *

Yes

No

Will the life insurance policy being applied for replace or change any annuity or life insurance coverage in force or pending? *

Yes

No

Bank Name *

Routing Number: *

Checking Account Number *

Due Date 1st-28th *

Payor Name (If Different than the Insured)

Payor's Billing Address