Ameritas Direct The No-Load Insurance Pioneer

1-800-555-0955

Get a Proposal

Please complete the follow information. Note that before we complete your proposal, an Ameritas Advisor representative will contact you by phone to briefly discuss how you plan to use your life insurance so your proposal can be tailored to your needs. When you receive your proposal, you will also receive a prospectus which provides detailed information about policy limitations, risks, charges and expenses. Please read it carefully before investing or sending money. Variable products have investment risk, including the possible loss of principal.

Delivery Information

Personal Title

First Name

Last Name

Address

Address 2

City

State

(not available in NY)

Zip

Fax

Daytime Phone

Alternate Phone

E-mail

How do you want your proposal delivered? e-mail/web land mail

Proposal Information

Insured Name (if other than above)

First Name

Last Name

Gender

Date of Birth

// (MM/DD/YYYY)

Tobacco Use

State of Residence

(not available in NY)

Amount of Insurance

Other Amount
(if "Other" selected in the previous box)

How do you plan to use this financial tool?

I'm primarily interested in the death benefit.

I'm interested both in the death benefit and building cash value on a tax-deferred basis.

I'm primarily interested in building cash value on a tax-deferred basis.

Other (input below)

Member Number

Comments and/or Questions

Before we deliver your proposal, an account representative will contact you by phone to briefly discuss how you plan to use this flexible financial tool so we can tailor the proposal to your specific needs.