**Information received from this Life Insurance quote request form sent to the
William Malloy Insurance Agency will be for our use only and will not be
sold, given to or distributed to any other parties. A quote will be based on the
life insurance policy information provided and does not guarantee acceptance
of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the
policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this
form does not entitle you to a Life Insurance policy. We are licensed in
Connecticut and will not provide quotes for other states.
In addition to Whole Life
and Term Life Insurance,
we also offer affordable
Connecticut Health
Insurance policy
premiums or choose
another personal
insurance coverage from
the list below.
We offer Whole Life and Term Life Insurance policy throughout Connecticut!
Applicant Information:
Term Life & Whole Life Insurance Coverage Information:
Life Insurance Quote
Personal Insurance
Quotes
(Connecticut)
Do you have questions about
term life or whole life
insurance policies?
Fairfield County Connecticut Insurance Agency
Malloy Insurance Agency
Connecticut Business, Home, Health
& Life Insurance Specialists
Copyright 2004-2008 William Malloy Insurance Agency, Inc. - All rights reserved
William Malloy
Insurance Agency
87 Glenbrook Road
Stamford, Connecticut 06902
(203) 351-9898
Fax: (203) 351-9880
"Your Fairfield County
Life Insurance Agent"
We are your local Fairfield County insurance agency, offering affordable whole
life and term life insurance policy services in the following Connecticut cities and
counties: Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown,
Springdale, Round Hill, Old Greenwich, East Norwalk, New Canaan, Glenville,
Byram, Cos Cob, Mianus, North Stamford, Glenbrook, Wilton, Weston, Long
Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport, North Wilton,
Winnipauk, Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown,
Ridgefield, Branchville, Redding, Topstone, Ridgebury, Redding Ridge,
Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel, Danbury,
New Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney,
Shelton, Huntington, Upper Stepney, Long Hill, Trumbull, Stratford, Easton,
Fairfield, Greenfield Hill, Stratfield, Nichols, Oronoque, Rivercliff, Devon, Lordship,
and East Bridgeport, New Haven, Hartford, Torrington, Waterbury, Meriden, New
Britain, New London, Norwich, Manchester, East Hartford, Suffield, Granby,
West Haven, West Hartford, Branford, East Haven, Hamden, Woodbridge,
Orange, North Haven, Groton, Rocky Hill, Newington, Wethersfield, Glastonbury,
Bloomfield, Blue Hills, South Windsor, Naugatuck, New Hartford, Chesire, East
Lyme, Old Mystic, Wallingford, Southington, Middletown, Bristol, Laurel Beach,
Litchfield, Pleasure Beach, Mystic, North Westchester, Double Beach,
Willimantic, Storrs, Canaan, East Windsor, Vernon, South Canaan, Putnam,
Guilford, Windham, South Britain, Willington, Windsor, East Hampton, Brooklyn,
Westchester, and everywhere else in New Haven County, Litchfield County,
Middlesex County, New London County, Hartford County, Tolland County and
Windham County, CT.
Term Life & Whole Life
Insurance Quote
Full Name:          
Home Address:
City:     State:     Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:
Date of Birth:              (mm/dd/yyyy)
Gender:    Height:  ft. 
Weight:    Do you smoke?

Do you currently have life insurance?   
Type of life insurance currently owned:
Current Premium:$  per month




Who will be insured:
Type of life insurance desired:       
Amount of Life Insurance Desired:    Other Amount:$ 
Benefit Period Desired:                 

Has anyone to be insured had health problems during the past 2 years
or been diagnosed with a serious illness?
If "Yes" to the question above, please list information below.


Are you currently taking any prescription or
over-the-counter medications?
If "Yes" to the question above, please list information below.

Medication Name:   Dosage:   Frequency:
Reason/Condition:

Medication Name:   Dosage:   Frequency:
Reason/Condition:

Does anyone to be insured have a hazardous job? Yes No
Is anyone to be insured an active member of the military reserves? Yes No

Additional Information or Comments



Click on the "Submit Quote Information" button below to send
your Term Life or Whole Life Insurance quote request.**