Client:
State of Res.
DOB:
Sex: Male Female
Tobacco Use? Yes No
Occupation:
Duties:
Owner? Yes No
# of Employees:
Travel%
Personal Income:
Quote Information:
Monthly Benefit $
Waiting Period: 30 60 90 180 365
Benefit Period: 1 2 5 Age 65
RIDERS Residual:
Return of Premium: Seven Year(50%)Pan Am only
Ten Year (80%)Pan Am only
25 Years or A65 Assurity-WALCO
Cola:
Simple
Future Increase Option:
Endorsed Group Discount:
Health Issues:
Medication(s):
Special Issues:
Does Client Own a Business? C-Corp S-Corp Sole
Part LLC PSC
Insurability Profile
1.Has proposed been treated for: A.Any disease or disorder of the heart or circulatory system, chest pains, high blood pressure, stroke; or lungs, including TB... Yes No B.Disease or disorder of the kidneys, bladder, geniro-urinary system, reproductive organs, breasts, skin, eyes, ears or speech... Yes No C.Disease or disorder of the stomach, intestines, colon, prostate, liver, including jaundice and/or hepatitis... Yes No D.Disease or disorder of the brain or central nervous system, including convulsions, seizures, paralysis, dizziness or fainting spells... Yes No E.Cancer, tumor, diabetes or any disease or disorder of the thyroid or lymph glands... Yes No 2.Has proposed ever been treated or had any indication or symptoms of any disease or disorder of the bones, muscles, joints, back or neck; or arthritis, neuritis or gout including any chiropractic treatment... Yes No 3.Has proposed ever consulted a psychiatrist, psychologist, counselor, therapist or any other practitioner for mental, nervous or emotional conditions including but not limited to anxiety, depression, stress or marital problems... Yes No 4.Has proposed ever used drugs or any controlled substance other than prescibed by a physician or been counseled or had treatment recommended from excess use of alcohol or drugs?... Yes No 5.Aquired Immune Deficiency Syndrome(AIDS);AIDS Related Complex(ARC); or positive HIV test?... Yes No 6.In the past 5 years has the proposed: A.Had any insurance application rejected or modified... Yes No B.Recieved or been refused any disability or medical benefits... Yes No C.Had any medical advice, operation, hospitalization, physical exam, treatment, illness, symptom or injury not listed above... Yes No
644 Linn Street,
Suite 1100