Your Life Insurance Source

We are a Maine based life insurance agency specializing in the sale and service of life insurance contracts for Georgia, Maine, Michigan, Oklahoma, North Carolina & Tennessee. Our mission is to shop the nations life insurance carriers to ensure that you receive the best rate that you are entitled too while providing a quick and unobtrusive quoting and application process.

At Langelier Insurance we make sure that you are informed about your insurance choices. When purchasing your life insurance plans through us you can feel confident that you are getting the best coverage and the most affordable price from quality insurance companies.

First Name: *
Last Name: *
Gender: * Male Female
Date of Birth: *
Height: *
Weight: *
Tobacco Use in last 12 Months? * No Yes
Amount of Life Insurance Needed: *
How long do you need this coverage? *
Phone Number: *
E-mail Address: *
State: *
Zip Code: *
In the past three years have you been convicted of a DUI, or had a drivers license suspended / revoked? * No Yes
Have you ever been treated for any of the following: Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar health conditions? * No Yes
Have any of your immediate family members (parents or siblings) had: Cancer, heart disease, stroke or an aneurism prior to the age of 70? * No Yes







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