formBurialFinalExpensePlanTodd

Home
Insurance
- Life
- Long-Term Care
- Accident
- Cancer
- Disability
- Dental >
  - Prepaid Plan
  - Insured Plan
- Vision
- Hospital Income
Annuities
D.R.O.P.
Forms
Contact Us
College Internship
About Us

Burial / Final Expense Plan

State Securities Corp offers both Simplified and Guaranteed Acceptance Coverage (may not be available at all ages). Without protection to help cover final expenses, these inevitable costs ‐ such as funeral and burial expenses, medical bills, and other debts ‐ could fall upon your loved ones. Final Expense coverage gives you peace of mind now, knowing you won’t leave a financial burden— and gives your family financial protection for the future.

Please complete the form below and we will send you a quote and additional information.

Proposed Insured's Information

* Indicates required field

Select One *

Date of Birth *

Please use MM/DD/YYYY format

Height *

Enter in Feet and Inches (example: 5'9")

Weight *

This quote is for? *

Myself Spouse My Parent Other

Has proposed insured ever used any nicotine products? *

Yes No

If the proposed insured has used nicotine products, when was the last date of use (MM/YYYY)? *

Please use MM/YYYY format

How much coverage would you like us to quote? *

$5,000 $10,000 $15,000 $25,000 - $50,000

Has proposed insured ever been treated for any of these conditions?
(Please select "Yes" or "No" for each condition)

Blood Pressure *

Yes No

Cancer *

Yes No

Diabetes *

Yes No

Heart Issue *

Yes No

Sleep Apnea *

Yes No

COPD *

Yes No

Our expert agents may be able to find affordable rates even for people with less than perfect health.

Please enter your information to get your free quote

Your Name *

Primary Phone Number *

Email Address *

If applicable, what State of FL Agency do you work for? (this policy may be payroll deductible) *

Comments (optional) *

If you have any comments you would like to share, please include them here.

Request Quote

NOTE: If you would like to get a quote for an additional person, please refresh this webpage and complete a new form after clicking the button above.