Multi-Life Offer Request Form

Capitas - Multi-Life Offer Request Form

  • Producer Information

  • Please Note: a Census Form is Required to Complete This Proposal Request

    Download the Excel spreadsheet census form by clicking here.

    You may attach the completed Excel file at the bottom of this form.
  • Case Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Multilife Case Design

  • Coverage InForce

  • Group LTD

    (Check all that apply)
  • Individual DI

  • Other Information

  • Census Form

  • Accepted file types: xls, xlsx.
    Don't have the Excel file?
    Download our pre-formatted Excel spreadsheet census form by clicking here.