73 Redding Rd.
P.O. Box 11
Georgetown, CT 06829

Phone (203) 544-9300
Fax (203) 544-9967
E-mail: info@gfginc.com

25 Broadway
Suite 101
Pleasantville, NY 10570
Phone (914) 747-4585
Fax: (914) 747-0188
Quote Request

Traditional Life Insurance Quote Request Form 
Fax 203-544-9967 or email info@gfginc.com

State:
Agent & Agency Name:
Agent E-Mail /Phone #
Agent Address:
Client Name:
Client DOB:
Rate Class:
Tobacco Use:
Sex:
Riders:
Payment Mode:
Face Amount:
SUL:
Spouse Name:
Spouse DOB:
Rate Class:
Tobacco Use:
TERM:
Number of Years of Coverage:
Universal Life:  
Number of Years of Guarantee (default is "all years")  
Number of Years to Pay (default is "all years")  
Requested Carriers:













   

For more complex cases, please contact Ronni Batista (Ext 21 or ronni@gfginc.com) or John DeSalva (Ext 12 or john@gfginc.com).

To submit a quote request to GFG please select and fill in one of the forms below:
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Securities and Investment Advisory Services offered through Representatives of Tower Square Securities, Inc., a securities Broker/Dealer (member FINRA/SIPC) and a Registered Investment Adviser. Georgetown Financial Group is not a securities broker/dealer or Registered Investment Adviser, and is a separate entity from Tower Square Securities, Inc.
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