Secura Consultants
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  • Exclusive Implementation Request


  • Include if you would like us to CC an additional contact on all case correspondence

    In order to correctly complete the application, we will need to know the full name of the writing advisor.

  • In order to correctly complete the application, we will need to know the full name of the writing advisor.

    We will need to information of all advisors who wish to be included on the application and the amount of commissions to be assigned to each.

  • We will need to information of all advisors who wish to be included on the application and the amount of commissions to be assigned to each.

    State licenses must be active with the proper line of authority before the application can be completed and signed.  Pre-appointment is not required with most carriers.

  • State licenses must be active with the proper line of authority before the application can be completed and signed.  Pre-appointment is not required with most carriers.

  • Please note if there is an additional contact we should include on all case correspondence.

  • We will be reaching out to the client to schedule an application phone appointment with our internal, licensed associate.

  • We will be reaching out to the client to schedule an application phone appointment with our internal, licensed associate.

    If a client is also applying for life insurance or has within the last 6 months, we can typically coordinate the lab requirements.  Please upload any life insurance lab slips below.

  • If a client is also applying for life insurance or has within the last 6 months, we can typically coordinate the lab requirements.  Please upload any life insurance lab slips below.

    It is important to know if any health concerns, occupation changes, or anything else that might affect underwriting has come up since we last communicated about this case.  This could affect underwriting and may change our recommendation.

  • It is important to know if any health concerns, occupation changes, or anything else that might affect underwriting has come up since we last communicated about this case.  This could affect underwriting and may change our recommendation.

  • Upload Files

  • Max. file size: 128 MB.

    This allows us to prepare an application based on the agreed upon carrier and plan design.  If applying for multiple products/carriers, please upload those below.

  • Drop files here or
    Max. file size: 128 MB.