Application and forms to be signed by customers

Application Forms

Application Forms are state specific – Please use the drop down box to go to the appropriate state and download Application Forms specific to your state. Application forms must be signed by the customer.

Outline Of Coverage (required in some states)

Some States also require an Outline of Coverage to be submitted with the Application Form and both documents must be executed by your client at time of solicitation. Please use the drop down box to go to the appropriate state to see if an Outline of Coverage is required and download it if needed.

Client Authorization Form

Authorization form must be signed by customer. The signed form is required for us to review client’s medical records.



Quote / Illustration Software and Worksheets

Quote / Illustration Software

The Quote and Illustration Software calculates premiums based on desired coverage. It also prepares Quotes that you can print and give to your customers.

Click here to see Installation Instructions.




Worksheet

If you prefer to manually calculate the premiums yourself, this simple excel worksheet will help you do that if you know the premiums for $100 of coverage for the plan and optional riders selected.


Product specific Flyers and Product Information

Brochures

Click on the drop down box to go to your specific state and download the product flyers you need.

To order printed color copies please go to the Flyer/brochure/kit order form

State Approval List

Download and print the most recent State Approval List

Since products are not available in all states, please refer to the State Approval List for a one page table with product availability in each state. This information is also in the Quick Reference Guide under the Availability tab.




State Specific Forms

 

 ALABAMA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application N/A N/A N/A N/A N/A FSL_a01082
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers N/A N/A N/A N/A N/A
FSL_PlatSelect_Flyer
 
 

 ALASKA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 ARIZONA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_AZ FSL_a00677_AZ FSL_a00677_AZ N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 ARKANSAS  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925 FSL_a00925 FSL_a00925 N/A FSL_a01041 FSL_a01082_AR
 Outline of Coverage FSL_SD19-D00037_AR FSL_SD18-D00037_AR
FSL_SD16_SD17-D00036_AR
N/A FSL_SD29-D00058_AR FSL_D00064_AR
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 CALIFORNIA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_CA FSL_a00677_CA FSL_a00677_CA N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 COLORADO  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_CO FSL_a00677_CO FSL_a00677_CO FSL_a00677_CO N/A N/A
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A N/A
 
 

 CONNECTICUT  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_CT FSL_a00677_CT FSL_a00677_CT N/A FSL_a01040_CT FSL_a01074_CT
 Outline of Coverage N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 DELAWARE  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 DC  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_DC FSL_a00677_DC FSL_a00677_DC N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 FLORIDA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application N/A N/A FSL_a00454FL396 FSL_a00454FL396 N/A TO BE FILED
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers N/A N/A
FSL_FL_Brochure

FSL_FL_Brochure
N/A N/A
 
 

 GEORGIA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01041_GA FSL_a01082_GA
 Outline of Coverage N/A N/A N/A N/A FSL_SD29-D00058_GA N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 HAWAII  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 IDAHO  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 FSL_a00677 N/A TO BE FILED
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A N/A
 
 

 ILLINOIS  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 INDIANA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_IN FSL_a00925_IN FSL_a00925_IN FSL_a00925_IN N/A FSL_a01082_IN
 Outline of Coverage FSL_SD19-D00037 FSL_SD18-D00037 FSL_SD16_SD17-D00036 FSL_SD16_SD17-D00036 N/A FSL_D00064_IN
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A
FSL_PlatSelect_Flyer
 
 

 IOWA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 KANSAS  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01082_KS
 Outline of Coverage N/A N/A N/A N/A N/A FSL_D00064_KS
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 KENTUCKY  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_KY FSL_a00677_KY FSL_a00677_KY N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 LOUISIANA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_LA FSL_a00925_LA FSL_a00925_LA N/A FSL_a01041 FSL_a01082
 Outline of Coverage FSL_SD19-D00037_LA FSL_SD18-D00037_LA FSL_SD16_SD17-D00036_LA N/A FSL_SD29-D00058_LA FSL_D00064_LA
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 MAINE  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application N/A N/A N/A N/A N/A N/A
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers N/A N/A N/A N/A N/A N/A
 
 

 MARYLAND  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_MD FSL_a00925_MD FSL_a00925_MD FSL_a00925_MD N/A TO BE FILED
 Outline of Coverage FSL_SD19-D00037_MD FSL_SD18-D00037_MD FSL_SD16_SD17-D00036_MD FSL_SD16_SD17-D00036_MD N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A N/A
 
 

 MASSACHUSETTS  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 MICHIGAN  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_MI FSL_a00925_MI FSL_a00925_MI FSL_a00925_MI N/A FSL_a01082
 Outline of Coverage FSL_SD19-D00037 FSL_SD18-D00037 FSL_SD16_SD17-D00036 FSL_SD16_SD17-D00036 N/A FSL_D00064_MI
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A
FSL_PlatSelect_Flyer
 
 

 MINNESOTA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_MN FSL_a00925_MN FSL_a00925_MN N/A FSL_a01041_MN FSL_a01082_MN
 Outline of Coverage FSL_SD19-D00037_MN FSL_SD18-D00037_MN FSL_SD16_SD17-D00036_MN N/A FSL_SD29-D00058_MN FSL_D00064_MN
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 MISSISSIPPI  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 MISSOURI  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_MO FSL_a00677_MO FSL_a00677_MO N/A FSL_a01040_MO FSL_a01074_MO
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 MONTANA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application PRODUCTS NOT
CURRENTLY OFFERED IN THIS STATE
 Outline of Coverage
 Brochures / Flyers
 
 

 NEBRASKA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 NEVADA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 NEW HAMPSHIRE  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 FSL_a00677 N/A N/A
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A N/A
 
 

 NEW JERSEY  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 NEW MEXICO  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_NM FSL_a00677_NM FSL_a00677_NM N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 NEW YORK  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application PLEASE CALL
866-747-5677 FOR MORE INFORMATION
 Outline of Coverage
 Brochures / Flyers
 
 

 NORTH CAROLINA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_NC FSL_a00677_NC FSL_a00677_NC N/A FSL_a01041_NC FSL_a01082_NC
 Outline of Coverage N/A N/A N/A N/A FSL_SD29-D00058_NC N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 NORTH DAKOTA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A
FSL_PlatSelect_Flyer
 
 

 OHIO  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_OH FSL_a00677_OH FSL_a00677_OH N/A FSL_a01040 FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 OKLAHOMA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01041 FSL_a01082_OK
 Outline of Coverage N/A N/A N/A N/A FSL_SD29-D00058_OK FSL_D00064_OK
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 OREGON  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925 FSL_a00925 FSL_a00925 FSL_a00925 N/A FSL_a01082_OR
 Outline of Coverage FSL_SD19-D00037_OR FSL_SD18-D00037_OR FSL_SD16_SD17-D00036_OR FSL_SD16_SD17-D00036_OR N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer

FSL_ExecPlat_Flyer
N/A
FSL_PlatSelect_Flyer
 
 

 PENNSYLVANIA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_PA FSL_a00677_PA FSL_a00677_PA N/A N/A FSL_a01082_PA
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A N/A
FSL_PlatSelect_Flyer
 
 

 RHODE ISLAND  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 SOUTH CAROLINA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_SC FSL_a00677_SC FSL_a00677_SC N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 SOUTH DAKOTA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application PRODUCTS NOT
CURRENTLY OFFERED IN THIS STATE
FSL_a01082_SD
 Outline of Coverage FSL_D00064_SD
 Brochures / Flyers
FSL_PlatSelect_Flyer
 
 

 TENNESSEE  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677_TN FSL_a00677_TN FSL_a00677_TN N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 TEXAS  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925_TX FSL_a00925_TX FSL_a00925_TX N/A FSL_a01041_TX FSL_a01082_TX
 Outline of Coverage FSL_SD19-D00037 FSL_SD18-D00037 FSL_SD16_SD17-D00036 N/A FSL_SD29-D00058 FSL_D00064_TX
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 UTAH  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A N/A FSL_a01082_UT
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A N/A
FSL_PlatSelect_Flyer
 
 

 VERMONT  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application PRODUCTS NOT
CURRENTLY OFFERED IN THIS STATE
 Outline of Coverage
 Brochures / Flyers
 
 

 VIRGINIA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 WASHINGTON  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00925 FSL_a00925 FSL_a00925 N/A FSL_a01041
FSL_a01082_WA
 Outline of Coverage FSL_SD19-D00037_WA FSL_SD18-D00037_WA FSL_SD16_SD17-D00036_WA N/A FSL_SD29-D00058_WA FSL_D00064_WA
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 WEST VIRGINIA  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040_WV  FSL_a01074_WV
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 

 WISCONSIN  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040_WI  FSL_a01074_WI
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
 
 WYOMING  
State Specific
Forms & Brochures
Blue Silver Platinum Series
Class
A / B
Class
AAA / AA
  Platinum Platinum Plus Platinum
eZ-Select
 Application FSL_a00677 FSL_a00677 FSL_a00677 N/A FSL_a01040  FSL_a01074
 Outline of Coverage N/A N/A N/A N/A N/A N/A 
 Brochures / Flyers
FSL_ExecBlue_Flyer

FSL_ExecBlue_Flyer

FSL_ExecSilver_Flyer
N/A
FSL_PlatPlus_Flyer

FSL_PlatSelect_Flyer
 
   

eZ-DI is brought to you by Risk Insurance and Reinsurance Solutions a global provider of specialized insurance solutions.
Insurance products are underwritten and administered by Fidelity Security Life Insurance Company, Kansas City, MO. Fidelity Security Life Insurance Company has been rated A- (Excellent), based on an analysis of financial position and operating performance , by A.M. Best Company, an independent analyst of the insurance industry.
This site generally represents the products underwritten by Fidelity Security Life Insurance Company, 3130 Broadway, Kansas City, MO 64111, but it is not a complete representation of them without the Policy's Explanation of Benefits, Exclusions and Limitations. Domicile: Missouri. NAIC No. 71870. Authorized to transact insurance in all states except NY.
Platinum Plus Group SD-28 / Policy Form No. M-4021; Platinum Plus Individual SD-29 / Policy Form No. M-4022; Platinum/Silver Group DI-139C & DI-139D / Policy Form No. M-4004; Platinum/Silver Individual SD-16 & SD-17 / Policy Form No. M-4012 /Policy Form No: M-00167/ Platinum eZ-Select Group SD-32, SD-33 / Policy Form No. M-4024; Platinum eZ-Select Individual SD-34 & SD-35 / Policy Form No. M-4025; Blue Group DI-141A; Blue Individual SD-18 & SD-19.