Final Expense Request





Broker Information

Agent Name*
Address
City
State
Zip
Email*
Phone*
Fax
Broker/Dealer
Return Method
FaxMailBroker pick-upEmail

Client Information

Name*
Date of Birth*
Gender*
MaleFemale

Health Class*

Health History

Tobacco Use
Cigarettes*
YesNo

If no, has use been discontinued?
YesNo

If yes, for how long?

Alternate Tobacco*

Marijuana*
YesNo
If yes, recreational or medical use?
RecreationalMedical
If medical usage, describe medical condition
Describe usage amounts per week
Family History
Cardiovascular or cancer death in parent or sibling prior to age 60
YesNo
If yes, provide details
Medical Factors
Blood pressure treatment?*
YesNo
If yes, provide details
Blood Pressure Reading*
Cholesterol treatment?*
YesNo
If yes, provide details
Cholesterol level*

Cholesterol/HDL ratio*

Medical History
Cancer?*
YesNo
If yes, provide details
Coronary/Diabetes?*
YesNo
If yes, provide details
Alcohol/drug treatment?*
YesNo

Other Impairments?*
YesNo
If yes, provide details

Non-Medical Factors
Number of moving/driving violations in the past 3 years*

Reckless driving/DUI suspension/revocation*
YesNo

Please provide details

Private Aviation*
YesNo

If yes, secure and complete aviation questionnaire

Commercial Aviation*
YesNo

If yes, secure and complete aviation questionnaire

Hazardous activities*
YesNo

If yes, provide details
Occupation*
If hazardous, provide details

US Citizen?*
YesNo

If no, provide details

Bankruptcy*
YesNo

If yes, provide details
Height*
feet
inches
Weight*
pounds

Illustration

Primary Objective
Death BenefitCash AccumulationGuaranteesLow PremiumFinal ExpenseLife + LTC
Face Amount(s)
Specified Carrier
Product Type

If Other, please specify
Level
-Pay
-Pay
To Age
1035 Rollover
Other Dump-In

Cash Value Target

Endow
Alternative Amount at Maturity or Age
Interest/Div Rate
Current or Other
%
AnnualSemi-AnnualQuarterlyMonthly

State of Issue

State in which insurance is to be used

Riders

Term Rider – Insured Amount: To Age
Term Rider – Other

Name
Date of Birth

Amount
To Age
Waiver of Premium
Child Insurance Rider
ADB
Other
Mail, phone and fax, if other than Agent Information
Additional Information
Appointment FormsApplication PacksProduct Information

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