Agent Info:

    Name:      

    Agency:     

    Address:    

    City:               State:      Zip:      

    Phone #:         Fax #:

    e-mail address: 

General Information:

    Clients Name:     DOB:  

    Sex:   Male Female      Issue state:      Smoker:   Yes No

    Class:   Preferred+         Preferred         Standard     

    Select (Preferred Smoker) 

    Rated    None A-1 B-2 C-3 D-4 E-5 F-6 G-7 H-8 I-9 J-10 K-11 I-12 M-13 N-14 Uninsurable    Flat Extra($):      Years: 

    Desired Company:              Face Amount:       

    Underwriter Consulted:      Date Consulted:   

    Premium:   Annual Semi-Annual Quarterly Monthly Check W/D Single Premium 1035 Exchange

   Rollover or 1035 exchange  amount    

  Type of exchange   N/A Qualified Non Qualifies

Term:

    30 Year     20 year     15 Year     10 year     5 Year     1 year

    Length of premium Guarantee:  N/A Full Guarantee 5 Year 10 Year 15 Year 20 Year    Second Choice:   N/A Not Requested Full Guarantee 5 Year 10 Year 15 Year 20 Year

Universal Life:

    Option   N/A Option 1 (CV and Term) Option 2 (CV+Term)

    Target Premium      Minimum Premium     

    Policy to run: Years or to age  with a cash value of

    at age @age

   or

    Premiums paid to age:    Desired Premium: 

  or

    Other, please describe:   

Whole Life:

    Dividend:   N/A One Year Term Paid Up Additional Insurance Paid In Cash Reduced Paid Up Insurance Accumulate at Interest

    Mix of Whole Life and Term, please describe:  

Riders:

   ADB      Amount  

    Waiver of Premium       One Year Term          

   Child Rider                   Other Insured Rider  

Additional Information:

    History / Problems and/or Medications:  

    Special Requests or comments: