Agent Name *

Email Address *

Phone Number

Fax Number

Date

Name *

Date of Birth *

Gender Male Female *

State

Tobacco Use Yes No *

Job Title

Duties

Annual Income

Annual Bonuses

Unearned Income

Business Owner? Yes No

If Yes, Years if Ownership

# of Fulltime Employees

Medical Conditions

Do you have Existing Coverage: Yes No

Type of Existing Coverage Individual
Group
Business

Existing Elimination Period

Existing Benefit Period

Monthly Benefit Cap

Taxable Benefits Yes No

Integrated w/ SS Yes No

Taxable Benefits Yes No

Benefit Period 2 Year
5 Year
To Age 65

Elimination Period 30 Days
60 Days
90 Days
180 Days
365 Days

Personal Select 90 180 365 730

Business Overhead Select 30 60 90

Buy/Sell Select 365 540 730

Personal Select 2 3 5 Age 65 Age 67

Business Overhead Select 365 15 Months 24 Months

Buy/Sell Select Lump Sum 2 Yr 3 Yr 5 Yr

Desired Amount

Quote Maximum

Cola %

Other

Please indicate any special health/underwriting considerations.

Additional Information