Reliable Financial Group, LLC
A CPS Marketing Organization
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Term Life Request
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Term Life Request
Broker Information
Broker Name*
Address
City
State
Zip
Email*
Phone*
Fax
Insured’s Information
Name*
Date of Birth*
Gender*
Male
Female
Health Class
—
Super Preferred
Preferred
Standard Plus
Standard
Health History
Tobacco Use
Cigarettes*
Yes
No
If no, has use been discontinued?
Yes
No
If yes, for how long?
—
1 year
2 years
3 years
4 years
5 years
Alternate Tobacco*
—
No
Pipe
Cigar
Chewing Tobacco
Nicotine Gum
Nicotine Patch
E-Cigarette
Marijuana*
Yes
No
If yes, recreational or medical use?
Recreational
Medical
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
Yes
No
If yes, provide details
Medical Factors
Blood pressure treatment?*
Yes
No
If yes, provide details
Blood Pressure Reading*
Cholesterol treatment?*
Yes
No
If yes, provide details
Cholesterol level*
—
300+
250-299
200-249
150-199
100-149
<100
Cholesterol/HDL ratio*
—
8.0 +
7.5 – 8.0
7.0 – 7.5
6.5 – 7.0
6.0 – 6.5
5.5 – 6.0
5.0 – 5.5
4.5 – 4.0
Medical History
Cancer?*
Yes
No
If yes, provide details
Coronary/Diabetes?*
Yes
No
If yes, provide details
Alcohol/drug treatment?*
Yes
No
Other Impairments?*
Yes
No
If yes, provide details
Non-Medical Factors
Number of moving/driving violations in the past 3 years*
—
5
4
3
2
1
0
Reckless driving/DUI suspension/revocation*
Yes
No
Please provide details
—
None in the past 5 years
None in the past 3 years
None in the past 2 years
Private Aviation*
Yes
No
If yes, secure and complete aviation questionnaire
Commercial Aviation*
Yes
No
If yes, secure and complete aviation questionnaire
Hazardous activities*
Yes
No
If yes, provide details
Occupation*
If hazardous, provide details
US Citizen?*
Yes
No
If no, provide details
Bankruptcy*
Yes
No
If yes, provide details
Height*
feet
inches
Weight*
pounds
Plan Information
Face Amount(s)*
Guarantee Period*
5 Year
10 Year
15 Year
20 Year
25 Year
30 Year
All
Use Non-Guaranteed Rates*
Yes
No
Issue State*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Premium Mode*
—
Annual
Semi-Annual
Quarterly
Monthly – EFT
Riders
Premium Waiver
Yes
No
ADB/AD&D
Yes
No
Return of Premium
Yes
No
Miscellaneous
Special Requests
Other
Your request can not be honored unless all required fields have been completed.
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