Advisor Details

Please provide your details

Advisor Name: Advisor Telephone Number:
Advisor Email:

Proposed Insured

Please provide proposed insured's details

Client Name (First, Middle, Last):
Date of Birth: Sex:
If past smoker, date last used:
SSN: Height: Weight: Driver's License Number: State of Issue:
Address (street, city, state, zip):
Place of Birth: Legal US resident: Yes No
Occupation: Income: Net Worth:
Business Address (street, city, state, zip):

Personal Physician

Please provide proposed insured's physician details

Physician Name: Physician Address (street, city, state, zip): Physician Phone Number:
Date physician was last seen: Reason for last visit:

Medical History

Please provide proposed insured's medical history

Please advise all medications the proposed insured is taking, the reason and for how long. Including herbal and over the counter medications and supplements:
Has the proposed insured been advised to have any tests or procedures that they have not yet had performed? If so please advise of details.:
Please advise of any surgeries or health conditions (include cancer, heart or vascular disease, diabetes, sleep apnea, ulcerative colitis, irregular hearbeat, mental or nervous conditions, hepatitis, anemia or blood disorder, etc). We have questionnaires to help with 'yes' answers for details to these conditions.:
Has the proposed insured had any life, health or disability insurance rated or declined? If yes, please provide details.:
Have the proposed insured's natural parents lived to at least age 60?:
Does the proposed insured's natural parents or siblings have a history of diabetes, cancer, stroke, or heart disease? If yes, please provide details.
Does the proposed insured participate in any hazardous avocations, ie aviation, scuba, motor vehicle/motorcyle racing, mountain/rock climbing? If so, please provide details including how often the proposed insured is engaging in this activity.:

Coverage Details

Please provide coverage details

Purpose of coverage: Owner of coverage:
How will this coverage be billed:
Annual Semi-Annual Quarterly Monthly
Please rate the following from 1-5 on level of importance to the proposed insured (1 being a top priority, non negotiable to 5 being of little relevance or importance)
a)Death Benefit Guarantee 1 2 3 4 5
b)Cash Value Accumulation 1 2 3 4 5
c)Acceleration of Death Benefit for short or long term medical expenses 1 2 3 4 5