Advisor Information
Advisor Name
*
First
Last
Company
Advisor Address
Street Address
Address Line 2
City
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
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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
State
ZIP Code
Email
*
Send to Additional Email?
Best contact phone number
Client Information
Applicant's age
*
Please enter a number from
0
to
90
.
Applicant's Date of Birth
Month
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Day
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Applicant's Name
First
Last
Applicant's Sex
*
Female
Male
Applicant's Marital Status
Married
Single
Tobacco History
*
None / Never Used
Cigarettes
Cigars
Chew
E-cigarettes
Currently Using?
*
Yes
No
Date of last use
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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2020
2019
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2014
2013
2012
2011
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2009
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2002
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1932
1931
1930
1929
1928
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1926
1925
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1923
1922
1921
1920
Health Rate Class
Preferred Best Non-Tobacco
Preferred Non-Tobacco
Standard Plus Non-Tobacco
Standard Non-Tobacco
Preferred Tobacco
Standard Tobacco
Please add any additional information or details about the rate class(es) selected that may help us during the quote process.
Is this a joint case?
Yes
No
Client #2 Information
Second Applicant's age
*
Please enter a number from
0
to
90
.
Second Applicant's Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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11
12
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25
26
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29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Second Applicant's Name
First
Last
Second Applicant's Sex
Female
Male
Second Applicant's Marital Status
Married
Single
Tobacco History
None / Never Used
Cigarettes
Cigars
Chew
E-cigarettes
Currently Using?
Yes
No
Date of last use:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Health Rate Class
Preferred Best Non-Tobacco
Preferred Non-Tobacco
Standard Plus Non-Tobacco
Standard Non-Tobacco
Preferred Tobacco
Standard Tobacco
Please add any additional information or details about the rate class(es) selected that may help us during the quote process.
Quote Information
Client 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
Primary objective
Death Benefit
Cash Accumulation
Retirement Income
Other objectives / needs
Key Man
Family Protection
Buy Sell
Loan / Debt Repayment
Other
If "Other' please explain:
Face amounts(s)
Describe
Level Death Benefit
Increasing Death Benefit
Solve for Death Benefit
Solve
Minimum
Maximum
Specified carrier
Product Information
Plan Type
Accumulation UL at Current Rate
Guaranteed UL
Variable UL
Index UL
Whole Life at Current Rate
Variable UL % Gross Rate Desired
Indexed UL % Gross Rate Desired
Permanent
Desired Interest Rate
Alternate Interest Rate
Is this a replacement?
Yes
No
Premium Options
Payment Mode
Single Premium
Monthly
Quarterly
Semi-Annually
Annually
1035 Exchange
Lump Sum
Solve Premium - Amount and number of years:
Riders
Riders Desired
Child Rider
Waiver of Premium
Accidental Death Benefit
LTC or Chronic Illness Rider
Child Rider: Specify gender, age & amount
Accidental Death Benefit: Specify Amount
Case Information
Are you in competition for this case?
Yes
No
If yes, please specify:
Additional comments or health concerns?
Submit Form
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Advisor 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
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