First Name        Last Name          Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Will this new policy replace current Annuity? Yes No

If you are replacing current Annuity please describe current contract provisions:

Type of Annuity  Immediate Annuity (Starts Paying Out Immediately) Indexed Annuity Fixed Annuity Annuity with Bonus paid on 1st year premium Multi-year Guaranteed Annuity    Preferred Carrier (If none, please enter None)

Single or Joint Life Coverage Single Joint            If Joint Coverage:  DOB of joint owner mm/dd/yyyy 

Payment Mode Single Premium Monthly Bank Draft Quarterly Semi Annual Payment Annual Payment     Premium Amount     Qualified Money  Non-Qualified Money 

For Immediate Annuity - Settlement Option  Life Life with 10 year certain 10 year certain 15 year certain 20 year certain 25 year certain 30 year certain Other      Desired Periodic Income Amount   payments Monthly Quarterly Semi-Annually Annually

For Multi-year Guaranteed 2-5 year rate guarantee 6-10 year rate guarantee 11+ year rate guarantee

First Name        Last Name       Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Will this new policy replace current insurance? Yes No

If you are replacing current policy please describe current policy provisions:

Dental Insurance Policy Goals  Full Coverage Insurance, no Discount Plans Coverage for preventative and minor work, discounts on other work Full Coverage on Preventative and Basic; partial coverage for Major Dental Work

Are you looking for Orthodontic Coverage Inclusion  No Yes             Specific Carrier you would like quoted: 

Deductible Level   $25 per family member / $75 Family Max $50 per family member / $150 Family Max     Coinsurance Level  100% Prevent / 100% Minor / 70% Major 100% Prevent / 70% Minor / 70% Major 100% Prevent / 50% Minor / 50% Major 100% Prevent / 70% Minor / 50% Major 100% Prevent / 50% Minor / No Major   (Amount Carrier Pays of Allowed Expenses)    Max Amount of Annual Coverage  $1,000 $1,500 $2,000 $2,500 Unlimited

First Name        Last Name       Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Will this new policy replace current insurance? Yes No

If you are replacing current policy please describe current policy provisions:

For Disability Insurance 1-5 years benefits 6-10 years benefits 11-15 years benefits 12-20 years benefits Benefits to Age 65         Current Salary    Percentage of Salary to Cover  70% 66% 60% 50%

Disability Coverage Desired  For Own or Same Occupation Only Any Occupation (Totally Disabled)

Medical Problems 

Medications & Dosage 

First Name        Last Name       Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Type of Insurance Requested    Term Life Insurance Whole Life Insurance Universal Life Insurance             Will this new policy replace current insurance? Yes No

If you are replacing current policy please describe current policy provisions:

For Term Life Insurance:

Amount of Coverage Desired       Desired length of initial coverage term 10 years 15 years 20 years 25 years 30 years        

Payment Frequency  Annual Quarterly Monthly (Bank Draft) Single Premium       Medical Conditions or Major Surgeries

Riders Requested:  Waiver of Premium No Yes     Accidental Death Benefit  No Yes    Child Life Protections  No Yes

For Whole Life and Universal Life:

Preferred Coverage   Universal Life Whole Life Best Policy based on Objectives    Objective of Life Insurance Guaranteed Death Benefit Only Cash Accumulation Low Premium Highest Death Benefit for Single premium Guaranteed Value Growth

Amount of Coverage Desired       Ht Wt

Medical Problems 

Medications & Dosage 

Premium Payment Method  Level Monthly Level Quarterly Level Semi-Annual Level Annual Pay to Age 65 Pay to Age 70       1035 Rollover  (Enter Dollar amount)

First Name        Last Name       Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Will this new policy replace current insurance? Yes No

If you are replacing current policy please describe current policy provisions:

For Long Term Care Insurance  Life Coverage Benefits 10 years Benefits 5-9 years Benefits 3-4 years Benefits 1-2 years Benefits        Coverage for Individual Only Individual and Spouse Individual and Domestic Partner

If more than one person to be covered enter data:  Second First Name    Last Name                                    Second person's DOB mm/dd/yyyy 

Desired Benefits  Nursing Home Care Only Nursing Home and At Home Nursing Care Nursing Home and Cash Indemnity Benefit Nursing Home, In Home Nursing Care, and Cash Indemnity Benefit

Amount of Daily/Monthly Benefit  $100 / $3,000 $110 / $3,300 $120 / $3,600 $130 / $3,900 $140 / $4,200 $150 / $4,500 $160 / $4,800 $180 / $5,400 $190 / $5,700 $200 / $6,000 More than $200/Day or $6,000/month $170 / $5,100   Cash Indemnity Benefit  None $1,000 per month $1,500 per month $2,000 per month $2,500 per month

Annual Inflation Protection 3% Annual Compound 4% Annual Compound 5% Annual Compound 6% Annual Compound Other Options None         Other Special Option Requests

Primary Applicant Medical Problems 

Primary Applicant Medications & Dosage 

Secondary Applicant Medical Problems 

Secondary Applicant Medications & Dosage 

First Name        Last Name       Sex  M F

Date of Birth    mm/dd/yyyy    State of Residence  Arizona Florida Ohio Missouri Texas Other

Street Address Line 1   Street Address Line 2 

City    State    ZIP

Day Phone xxx-xxx-xxxx    Night Phone xxx-xxx-xxxx  

Cell Phone   xxx-xxx-xxxx    Fax    xxx-xxx-xxxx

E-Mail Address    

Tobacco Use     None Quit Pipe Chewing Cigar Cigarette     If Quit please indicate date quit   mm/dd/yyyy

Type of Insurance Requested    Cancer Coverage Heart Attach and Stroke Coverage Hospital Indemnity             Will this new policy replace current insurance? Yes No

If you are replacing current policy please describe current policy provisions: