State of Maine
Life Insurance
Online Quote Request

A service of Blake, Hall & Allen Insurance
170 Ocean Street South Portland, ME  04116-2403 (207)799-5541

Please provide the information below to receive a
Life Insurance Quotation.
This service is currently available only for residents of the State of Maine.

We will email your quote, usually within two business days.
Submit as many optional quote requests as you would like.

General Information

Name:

Address:

City, State, ZIP:

Phone #:

Home

Work

email address:

Information about Proposed Insured

Name:

Date of Birth:

Height:

Weight:

Tobacco User?

Yes

No

Any Medical History of:

Heart Disease?

Cancer?

Diabetes?

Cholesterol Problems?

Other Medical Problems?

Any family history of any of the items listed above?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

In the space below, please provide details of any question answered "yes" above, and make any other comments that you would like to include . Thank you for requesting an online quote.

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© Blake, Hall & Allen Insurance
170 Ocean Street 
South Portland, ME  04116-2403 
(207) 799-5541    (800) 373-5541
Maine Resident Producer Agency #AGR29506