Financial Services Broker Requests

For information: http://www.assetbasedltc.com/

Golden Rule is committed to providing you, the broker, with a fast, efficient means of gaining more information about our products and services. Please complete the requested information. In order to respond to your questions effectively, we require answers to items marked with an asterisk (*). *Name: Broker No.: Organization: *Address 1: Address 2: *City: *State: *ZIP Code: Phone: Fax: *E-mail Address: Your Question: Are you an Independent Broker? Yes No Do you have a licensing agreement with Golden Rule through another insurance company? Yes No How would you prefer to receive our response? (Please choose one.) E-mail U.S. Mail Telephone Fax