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? Personal 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.
Please check any dependents relying on financial support from Proposed Insured: Purpose of insurance (check all that apply): 1st Proposed Insured: Current Annual Household Income Gross Compensation (e.g. Salary, Commissions, Bonuses, etc.): Other Income (e.g. Dividends, Interest, Net Real Estate Income, etc.): Total Annual Cash Income before taxes: 1st Proposed Insured: Net Worth (excluding any business interest) Liquid Assets (assets that can be easily changed to cash): Other assets: Liabilities: Net Worth (excluding business): 1st Proposed Insured: Business Value Business Value: Is there a second proposed insured? Does the proposed insured have a personal accountant/CPA? Have either the proposed insured (s) or owner filed for bankruptcy within the past five years? Please provide additional details about the proposed insured(s) that might help us understand the financial history. Does the proposed insured take any medications (prescription or otherwise) at this time? Please provide additional details about the proposed insured’s medical history: