Agent's Phone Number: * Agent's Email: * State of Issue/Delivery: * 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 Send to Additional Email? Proposed Insured's Name: * What is the proposed insured's: *
Please select "age" if the date of birth is unknown.
Height: * Weight: * Ever a marijuana/THC user? * Ever a cigarette smoker? * Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) * Is this case being premium financed? * Face Amount: * Are there multiple policies/face amounts? Are you requesting any riders? Business Financial Statement
Note: Please complete this form in its entirety, completing the first section and each additional section that applies. This form is meant to be a tool to assess your client’s financial position as it applies to their insurability. Carrier financial supplements may still be required. Please refer to the accompanying pages for our financial underwriting guidelines. If your situation falls outside of these guidelines, please contact Terri Getman, JD, CLU, ChFC, RICP, AEP (Distinguished) at x230.
When was the business established?
If multiple, interrelated businesses exist, please note details at the end of this form. Please include a copy of the most recent Profit & Loss/Income Statement to provide the best advice possible.
Profit & Loss/Income Statement
The proposed insured is an: List amount of business insurance in force and applied for in all companies on each officer or member of the business. Name Age Ownership % In force Amount Am’t Applied For Name Age Ownership % In force Amount Am’t Applied For Name Age Ownership % In force Amount Am’t Applied For Name Age Ownership % In force Amount Am’t Applied For Name Age Ownership % In force Amount Am’t Applied For Purpose (Please check all that apply): Does the proposed insured take any medications (prescription or otherwise) at this time? Please provide additional details about the proposed insured’s medical history:
Please provide additional details about the proposed insured(s) that might help us understand the financial history.