American Insurnet A Cincinnati Company
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PERMANENT LIFE QUOTE
Required fields are marked with an asterisk.
Caller:
Agent:*
 State Application Will Be Signed In:
Date of Appointment:
Agent Information Checklist
Agency:
Address:
Contracts:
Case Status:		 Phone Number:*
Fax Number:
E-Mail:*
How would you like your quote returned to you?  Email  Faxed  Mailed
Personal Information


Client Name:

Sex:  Male  Female

Date of Birth:
Age Last:
Age Nearest:


Does the Client use any form of tobacco?:  Yes  No

If yes, which kind?:


How often?:

If no, have they ever?:
Yes  No

How long since they last used tobacco?:(months)

Client's Height:
Weight:
Cholesterol:
HDL Ratio:
Blood Pressure:

Types of Medication Taken:


Amount:
How Often:
For What:
Additional Medication:
Amount:
How Often:
For What:

Hazardous Activities?:
PILOT  SCUBA
SKYDIVING  RACING

Other Impairments?:
Yes  No
(Put Details in Additional Notes)


Father's Age L/D  L  D
Cause of Death:
Mother's age L/D  L  D
Cause of Death:

Is this a replacement case?:  Yes  No

If yes, what was the previous underwriting class?:

When?:
Based Upon This Information The Preliminary Risk Classification
To Be Quoted Will Be:


Face Amount(s):
Premium:

Mode:
Annually  Semi-Annually
Quarterly  Monthly(PAC)

Yrs to Pay:
Carry to Age:
Cash Value of:

Death Benefit Option:
Level  Increasing  Change

Lump Sum:  Yes  No
1035?:  Yes  No

Withdrawals/Loans:

Beginning AgeforYears
Leaving $at Maturity

RIDERS
WP  Yes
AD  Yes
CTR$
STR$

Competition:
Price:

What is the purpose of this coverage?:
Income  DB

Is there a specific company you want quoted?:


Additional Notes:

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American Insurnet Agency, Inc.644 Linn Street, Suite 1100Cincinnati, OH 45203800.333.4638