Permanent Life 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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