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(800) 891-1226
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(800) 891-1226
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Business
Business Insurance Solutions
Business Property Coverage
General Liability
Automobile Liability
Workers Compensation Insurance
CyberRisk Liability
Specialty Coverages
Personal
Personal Insurance Solutions
Home Insurance
Auto Insurance
Boat and Yacht Insurance
Umbrella Policies
Jewelry, Fine Art, and Valuables Insurance
Flood Insurance
Individual Life Insurance
Trip Insurance
Employee Benefits
Employee Benefits Solutions
Individual Life Insurance
Client Services
Client Services
Client Support
Claims
Incident Reports
Request a Certificate
Pay a Bill from IMA
Pay a Bill from Your Insurance Company
Registry
Request a Life Insurance Quote
Life Insurance Information
Type
Primary
Secondary
Amount of Death Benefit
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
$1,000,000+
Insured Basic Information
First Name
Last Name
Email
Home Phone
Gender
Male
Female
Use Tobacco?
Yes
No
Height
Weight
Address
Address
City
State
Zip Code
Insured Medical Information
Describe any pre-existing health conditions
Spouse Insurance Information
Spouse to be Insured?
Yes
No
Spouse Use Tobacco?
Yes
No
Spouse Gender
Male
Female
Height
Weight
Spouse Medical Information
Describe any pre-existing health conditions
Children
Any Children?
Yes
No
Child 1 Gender
Male
Female
Child 2 Gender
Male
Female
Child 3 Gender
Male
Female
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency
Weekly
Monthly
Yearly
Other Disability Coverage?
Yes
No
Other Disability Coverage Type
Individual
Group
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