Incorporated in 1996 general agent center inc. is a family-owned disability insurance brokerage agency located in Scarborough, Maine.
We have strong relationships with our agents and the insurance companies that we represent. Our reputation is built on Experience, Knowledge and Service.

Producer DI Illustration Request

State

Proposed Insured's First Name:

Proposed Insured's Last Name:

DOB:

Tobacco User?

Yes No

Gender:

Male Female

Provide the material and substantial duties of the Proposed Insured's occupation:

Business Owner:

Yes No

Years in business:

Number of Employees:

Full-time Part-time

Income

Annual Income:

Medical Information

Height:

Weight:

Is the Proposed Insured currently prescribed medications?

Yes No

Proposed Insured's medications and/or medical conditions:

Plan Design

Monthly Benefit Requested:

Benefit Periods:

2 years 5 years 10 years Age 65 Age 67

Elimination Periods:

60 Days 90 Days 180 Days 365 Days

Additional information:

Producer Information

Name:

Email Address:

Phone Number:

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Contact Us

MICKEY SILEO
DHP, DIA, DIF, EHBA, HIA ®

General Agent Center Inc.
3 Earles Way
Scarborough, ME 04074

Cell 207.749.8332

Note to customers: Your information will never be collected and sold/given to any 3rd Party and is only used by General Agent Center Inc. to contact you.