State of Missouri Insurance Quote Form
Please complete and submit all
*required fields.
Allstate Enrollers Western/Central Regions
Allstate Enrollers Eastern/South Regions
Lisa Peterson
[ statewide ]
913-522-3457
Carl Schick
314-504-5661
Carol Ann Gomez
816-215-4898
Kelly Shaffer
573-631-2625
Jay McDaniel
816-372-0659
Or Allstate Call Center 866-891-4149
Jennifer McNutt
816-588-1022
Monday thru Friday 8am - 4pm
PERSONAL INFORMATION
Name
Birthday
First Name
*
Last Name
*
Department
Month
*
Day
*
Year
*
City:
Daytime
Phone:
123
*
456
*
7890
*
Tobacco Usage
*
No
Yes
CRITICAL ILLNESS COVERAGE
Person(s) Applying for Coverage
Desired Amount of Coverage
Employee Only
Employee + Child(ren)
Employee + Spouse
Family
$5,000
$10,000
$15,000
UNIVERSAL LIFE COVERAGE
Coverage Desired
Long Term Care Rider
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$100,000 & Up
Yes
No
Unsure
EMAIL REPLY CONFIRMATION
Email Address
*
