AppVantage Advisor Data Collection Form
Advisor Information
Advisor Name
*
First
Last
Advisor Email
*
Account
*
Ameriprise
Non-Ameriprise
Client Information
Insured Full Legal Name
*
First
Middle
Last
Owned by individual?
*
Yes
No
Total insurance program: Currently inforce:
*
Total insurance program: Pending applications:
*
Relationship to proposed insured:
*
Date of birth:
*
Month
Day
Year
Earned annual income:
*
Unearned annual income:
*
Net worth:
*
Why will this person own the contract?
*
Business Insurance
Estate Tax
Support for Insured
Final Expenses
Is there a second insured?
*
Yes
No
Second Insured's Name
First
Middle
Last
Second Insured's Email Address
Second Insured's Date of Birth
Month
Day
Year
Is the Owner other than the Insured?
*
Yes
No
Owner Full Legal Name
First
Middle
Last
Trust Name
Trust Date
TIN
Trust - State of Residence
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Insured's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this a New York Case?
*
Yes
No
Is the insured a U.S. Citizen?
*
Yes
No
Is Insured a green card holder?
*
Yes
No
Is Insured a Visa holder?
*
Yes
No
Insured's Email Address
*
Insured's Phone Number
*
Insured's Gender
*
Male
Female
Insured's DOB/Age
*
Insured's Social Security Number
*
Insured, Trust, Business, etc.
Financial Information on the Insured
Annual Income
*
Net Worth
*
Other Income?
Binding Coverage?
*
Yes
No
Does the Insured have Existing Life Insurance?
*
Yes
No
Existing Coverage Information
*Include Carrier and Policy Date for all existing policies
Include Details here.
Does the client have a prior exam (completed within the past year) that they would like to use for this policy?
*
Yes
No
Does the client have a Riversource file?
*
Yes
No
Does the client have another pending DBS file/application?
*
Yes
No
Please list case information.
Who is ordering Exam/APSs?
*
DBS
Advisor
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