Permanent Quote Request LM

Advisor Information
Advisor Name*
First Last
Company
Broker Dealer / Agency Affiliation*
Advisor Address
Street Address Address Line 2 City State ZIP Code
Email*
Additional e-mail to CC illustrations to
Best contact phone number*
Client Information
Applicant's Name*
First Last
Applicant's Date of Birth*
Note: If you do not know the birthday, you can put January 1st and the appropriate year.
Applicant's Sex*
Tobacco Use*
Health Rate Class*
Please add any other details that may assist in underwriting
Marital Status*
Are we running anything for the spouse?*
Client #2 Information
Applicant's Name*
First Last
Applicant's Date of Birth*
Note: If you do not know the birthday, you can put January 1st and the appropriate year.
Applicant's Sex*
Tobacco Use*
Health Rate Class*
Please add any other details that may assist in underwriting
Are we running this as a joint survivorship policy or two individual policies?*
- Joint Survivorship
- Two Individual Policies
Are we doing the same design for the spouse or something else? Please note any changes in the comment sections to follow.
Quote Information
Writing State*
Primary Objective*
Please add any other details they may be looking for in a policy
Please select one of the following*
- Desired Face Amount
- Desired Premium
Desired Face Amount*
Desired Premium*
Is the writing agent licensed to sell variable products?*
- Yes
- No
Any preferred carriers or carriers to avoid? Please be specific as to your wishes.
Premium Information
Premium mode*
How many years do you want to illustrate premiums?
1035 Exchange
Is there an outstanding loan on the 1035?
- Yes
- No
Please provide more details
Lump Sum
Desired riders or any other notes we may need to know to best assist your clients?
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Your completed form is automatically routed to your dedicated Regional Case Design Analyst, determined by your geographic location. Please confirm your state and click SUBMIT below.
Advisor State*

Advisor Information

Client Information

Client #2 Information

Quote Information

Premium Information

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