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Contact Us
915 Saxonburg Blvd, Suite 217
Pittsburgh, PA 15223
Telephone: (412)782-1979
Toll Free: (800)235-2013
Fax: (412)782-2868
eMail: info@nimbroker.com
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Life Insurance Applications & Forms
Below, organized by carrier, are the available plan applications & forms with links to the plan brochures.
Click on the link to jump to the carriers materials:
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American Continental
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Assurity Life
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Banner Life
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Fidelity Life
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Genworth Financial
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ING
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John Hancock
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Lincoln Financial Group
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Met Life
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New Era Life
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Presidential Life
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Prudential Life
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United Home Life
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United of Omaha
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West Coast Life
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Western and Southern Life
American Continental
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ACI Final Expense PA Application (3-2011)
Links:
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Goto Agent Licensing
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Goto Final Expense Product Materials
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Visit American Continental’s Website
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Top
Assurity Life
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Simplified Whole Life PA Application (10-2009)
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Whole Life/Term/Universal Llife PA Application (4-2009)
Links:
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Goto Agent Licensing
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Goto the Whole Life Product Materials
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Goto the Assurity website
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Top
Banner Life
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Banner Life PA Application (10-2008)
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Banner Application Assist Short Form (5-2009)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials
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Visit Banner Life’s Website
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Top
Fidelity Life
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PA Accidental Death Application (5-2010)
Links:
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Goto Agent Licensing
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Top
Genworth Financial
Pennsylvania Materials:
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Genworth Life
PA
Application Kit
PA
Application Kit Components:
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Genworth PA Full Application (1/2010)
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PA ABDR Disclosure (12-2008)
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PA Agent Cert Form (12-2008)
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PA Disclosure Statement (6-2008)
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PA HIPAA Form (6-2008)
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PA HIV Form (6-2008)
PA
Miscellaneous Forms:
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GLAIC App Part II PA (5-2008)
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GLAIC ADBR Disclosure.pdf (4-2008)
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GLAIC Child Rider Application (2-2008)
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GLAIC Collateral Assignment (8-2009)
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GLAIC EFT Form (12-2008)
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GLAIC HIPAA Form (4-2008)
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GLAIC HIV Form (10-2006)
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GLAIC Ownership & Beneficiary Change Form (4-2008)
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GLAIC PA Disclosure Form (4-2008)
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GLAIC PA Replacement Form (12-2008)
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GLAIC-FCL Change Form (4-2006)
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PA Agent Disclosure Cert (12-2008)
Maryland Materials:
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GLAIC
MD
Application Kit (11-2009)
MD
Miscellaneous Forms:
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GLAIC-MD-Tax Statement (4-2010)
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MD HIPAA Form (3-2009)
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MD HIV Consent Form (3-2009)
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MD Replacement Form (5-2009)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials
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Visit Genworth’s Website
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Top
ING
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ING PA Term Application (11-2007)
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ING WV Term Application (11-2007)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials
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Visit ING’s Website
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Top
John Hancock
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PA Universal Life Application (5-2010)
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Buy Sell Brochure (5-2010)
Links:
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Goto Agent Licensing
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Top
Lincoln Financial Group
GTO STO ProTerm UL Products:
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LNC MD Term and UL Application (9-2008)
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LNC PA Term and UL Application (6-2008)
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PA Disclosure Statement (10-2004)
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PA Replacement Form (8-2006)
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Child's Term Rider Application (10-2004)
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HIPAA Authorization Form (8-2004)
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HIV Form (8-2004)
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Reinstatement Application (2-2010)
PA Universal Life Product:
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PA Universal Life Application (9-2009)
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PA 1035 Exchange Form (9-2009)
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PA Replacement Form (9-2009)
Life Elements Product:
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PA Term Application (7-2009)
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Disclosure Form (4-2008)
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HIPAA Authorization Form (4-2008)
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HIV Consent Form (4-2008)
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Replacement Form (4-2008)
Life Stratos Product:
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PA Term Application (4-2008)
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Disclosure Form (4-2008)
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HIPAA Authorization Form (4-2008)
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HIV Consent Form (4-2008)
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Replacement Form (4-2008)
Miscellaneous Forms:
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Client Service Request Form (5-2006)
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Life Policy Service Request Form (5-2006)
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1035 Exchange Form (4-2008)
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Collateral Assignment Form (5-2008)
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EFT Form (8-2004)
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PAC Bank Draft Form (3-2007)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials
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Visit Lincoln Financial Group’s Website
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Top
Met Life
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PA Application (12-2008)
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DE Application (1-2010)
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MD Application (6-2009)
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Child Rider (5-2009)
Links:
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Goto Agent Licensing
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Top
New Era Life
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New Era Platinum Whole Life PA Application (01-09)
Links:
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Goto Agent Licensing
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Top
Presidential Life
Graded Benefit Life:
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PA GBL Application (3-2009)
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PA Disclosure Form (4-2006)
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MD GBL Application (3-2009)
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DE GBL Application (3-2000)
Miscellaneous Forms:
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Change of Beneficiary Form (4-2005)
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EFT-Direct Debit Authorization Form (9-2007)
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Policy Change Form (7-2009)
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Presidential Owner (1-2007)
Links:
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Goto Agent Licensing
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Top
Prudential Life
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PA Express Application (06-2010)
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PA Disclosure Statement (2-2008)
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PA Replacement Form (9-2007)
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MD Express Application (3-2010)
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DE Express Application (9-2009)
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WV Term Application (4-2010)
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WV Express Application (6-2010)
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EFT Form (4-2007)
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HIV Form (5-2008)
Miscellaneous:
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Beneficiary & Ownership Change Form
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials & Build Charts
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Top
United Home Life
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PA Whole Life Application (6-2011)
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DE Whole Life Application (6-2011)
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MD Whole Life Application (6-2011)
Miscellaneous Forms:
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EFT Authorization (5-2010)
Links:
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Goto Product Materials
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Goto Agent Licensing
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Top
United of Omaha
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PA Express Term Application
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PA Express Whole Life Application (1-2008)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials & Rate Charts
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Top
West Coast Life
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PA Application (11-2009)
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PA TeleLife Packet (1-2008)
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TeleLife Presentation (1-2008)
Links:
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Goto Agent Licensing
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Goto the Term Life Product Materials
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Visit West Coast Life’s Website
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Top
Western and Southern Life
Effective December 31, 2011 Western & Southern will be withdrawing its Graded Benefit Whole Life product from the marketplace. No applications can be sold after this date.
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Top
The Medicare Frontier
Today’s Fastest Growing Market
::
Senior Product Home
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Senior Product Materials
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Applications & Forms
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Training & Certification
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Licensing Forms
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Request a Plan Comparison
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