Request a Quote
Need a quote for your valued client?
Fill in our quick “On-Line Quote” form and our underwriters will review your details and respond in 1 to 2 business days!
Application
Ready to fill out your Application?
Fantastic! Application Forms are state specific. You will need to download Application forms specific to your state. Application forms must be signed by the customers.
Start your “Application Now!”
Outline Of Coverage
Need an OutLine of Coverage?
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. When necessary, you’ll find these on the “Application Page.”
Client Authorization Form
Submitting medical information?
In order for our underwriters to review a client’s medical records, you must first print the HIPAA Authorization form and have it SIGNED by your by customer.
Please review the form *here*. Once signed you can fax to 954.642.2521 or scan and eMail to prelims@nonstandarddi.com.
Thank you!