Accidental Death Insurance

Complete your accidental death application online in a few steps.

Contact Information

Enter applicant details exactly as they should appear in the policy.

First Name

Middle Name

Last Name

Suffix

Phone Number

Email Address

Home Address

Apt/Suite

City of Living

State of Living

Country of Living

Zip Code

Important disclosure

Not available in New York

This policy may contain reductions of benefits, limitations and exclusions. Click here for standard Limitations and Exclusions. Product availability, features, rates, limitations and exclusions may vary by state. For costs and complete details of the coverage, please contact your insurance representative or Assurity to review the policy for more information. The state specific policy form is the ultimate authority for any questions about this product.

Policy Form No. I H2203, Rider Form No. R I2204 and if made available, associated Form Nos. R I2205, R I2208 underwritten by Assurity Life Insurance Company, Lincoln, Nebraska.

IMPORTANT NOTICE - This policy provides ACCIDENT INSURANCE ONLY. This policy DOES NOT PROVIDE COVERAGE FOR SICKNESS.

Assurity reserves the right to order, at the company's expense, evidence of insurability which the company feels is necessary for the prudent evaluation of the risk on any application.

Assurity is a marketing name for the mutual holding company Assurity Group, Inc. and its subsidiaries. Those subsidiaries include but are not limited to: Assurity Life Insurance Company and Assurity Life Insurance Company of New York. Insurance products and services are offered by Assurity Life Insurance Company in all states except New York. In New York, insurance products and services are offered by Assurity Life Insurance Company of New York, Albany, NY. Product availability, features and rates may vary by state.

Quotes are for informational purposes only and are not intended to constitute an offer of insurance. Issuance of a policy and premiums are subject to the accuracy of information provided, and underwriting guidelines and approval.