AppVantage CDA Data Collection Form
Person Submitting Request
Your Name
First
Last
Your Email
*
Advisor Information
Advisor Name
*
First
Last
Advisor Email
*
Are there multiple advisors or any other office contacts (i.e. assistant) who will be assisting in completing this application?
*
Yes
No
Please list first and last name and their email address
Client and Plan Information
Client's Name
*
First
Last
Client's Email Address
*
Client's DOB/Age
*
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
Ownership
*
Insured, Trust, Business, etc.
Carrier
*
Select Carrier
Allianz
AIG
Athene
Banner Life
Companion Life of NY
Equitable
Foresters
Global Atlantic
John Hancock
Lincoln Financial
Mass Mutual
Mutual of Omaha
Nationwide
National Western
New York Life
North American
One America
Pac Life Lynchburg
Pacific Life
Principal
Protective Life
Prudential
Securian
Security Mutual
Symetra
Transamerica
Voya
William Penn of NY
Zurich
Product Type
*
UL
SUL
IUL
SIUL
VUL
SVUL
Whole Life
Other
Please List Product Type
Product
*
State
*
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Face Amount
*
Are there any riders?
*
Yes
No
Please list any riders.
LTC
*
Yes
No
1035 Exchange
*
Yes
No
Replacement?
*
Yes
No
Is this a New York case?
*
Yes
No
Date policy to save age?
*
Yes
No
Copy of Illustration being sold OR BEST MATCH
*
Drop files here or
Select files
Max. file size: 50 MB.
Additional Notes
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