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Life & Health Insurance Request

You may use the form below to submit a request for life insurance directly to our qualified agents. We will contact you shortly after receiving the request. No changes will be bound until you recieve confirmation from our office upon review.

City State Zip
Home Phone Work Phone
Date of Birth Do you use tobacco in any form? YesNo
Amount of Coverage
Type of coverage desired? Term LifeUniversal LifeHealthGroup Health
*Please send us a census for our group health benefits package


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The Shannon Agency
Timothy G. Shannon, CLF, AIM, LUTCF

Phone: (800) 999-5729
Fax: (877) 625-9370