Request Information – SMile Shield Policy

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Name

First

Last

Address

City

State

Zip Code

Phone

Date of birth

Gender

Coverage Amount

Martial Status

Height (In inches)

Weight (in pounds)

Currently Insured ?

Insurance Type

I accept the terms of service below

By “submitting”, I provide my express written consent via this chat / webform interaction for a licensed sales agent associated with Smile shield policy, Allied insurance and all Marketing Partners to contact me from at the number I provided, even if the phone number provided is on the National Do Not Call registry, via live, automated dialing system telephone call, text, or email. I understand this request has been initiated by me and that this is an unscheduled contact request. I understand my telephone company may impose charges on me for these contacts and am not required to enter into this agreement as a condition of any purchase or service. I further understand that this request, initiated by me, is my affirmative consent to be contacted which is in compliance with all federal and state telemarketing and Do-Not-Call laws. Licensed Sales Agents are not connected with or endorsed by the U.S. government or the federal Medicare program. I agree to the Privacy Policy and Terms of Service. Please note this is a solicitation for policy.