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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