Have Us Run It Permanent Quote RequestTerm Quote RequestAnnuity Quote RequestLTC Quote RequestDI Quote Request Broker InformationAgent Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Business Phone*FaxCell PhoneClient 1 InformationApplicant's Name First Last Applicant's Date of Birth MM slash DD slash YYYY Applicant's Sex Female Male Tobacco HistoryNoneCigaretteCigarChewCurrent or date of last use:Client 2 InformationSecond Applicant's Name First Last Second Applicant's Date of Birth MM slash DD slash YYYY Second Applicant's Sex Female Male Tobacco HistoryNoneCigaretteCigarChewCurrent or date of last use:What rate class should be quoted?Quote InformationState of quoteSpecified carrierFace amounts(s)Primary objective Death Benefit Cash Accumulation Retirement Income Other objectives / Needs Key Man Family Protection Buy Sell Other If "Other' please explain:Product InformationPayment Mode Single Premium Annual Semi-Annual Quarterly Monthly Full Pay Short Pay Short Pay OptionsSuspend Pay - At ageSuspend Pay - In Specific YearPlan Type Universal Life Index UL Survivorship UL Variable UL Whole Life Additional Premiums1035 ExchangeLump SumDeath Benefit Option Level Increasing RidersRiders - Child RiderSpecify Gender, Age, & AmountRiders - Waiver of Premium Yes No Riders - Accidental Death Benefit Yes No Specify Amount:Case InformationAre you in competition for this case? Yes No If yes, please specify:Additional comments or health concerns? Δ Agent’s Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Business PhoneFaxCell PhoneClient InformationApplicant’s Name First Last Date of Birth MM slash DD slash YYYY Applicant’s Sex Male Female Tobacco HistoryNoneCigaretteCigarChewWhat rate class should be quoted?State of QuoteSpecific Carrier(s)Face AmountTerm Guarantee PeriodsYRT5 Year10 Year15 Year20 Year25 Year30 YearPremium ModeSelect OneAnnualSemi-AnnualQuarterlyMonthlyPlan TypeRidersRiders - Child RiderSpecify Gender, Age, & Amount Waiver of Premium Yes No Accidental Death Benefit Rider Yes No Are you in competition for this case Yes No If yes, please specify:Additional comments or health concerns? Δ BrokerName* First Last Phone*Email* ClientAnnuitantName* First Last Birthdate* MM slash DD slash YYYY Gender* Male Female Joint AnnuitantName First Last Birthdate MM slash DD slash YYYY Gender Male Female AnnuityInsurance Company Preference, if anyState of Issue*Tax Qualified* Yes No Annuity Type*Choose OneDeferred AnnuityImmediate AnnuityAdditional InformationPlease list any additional comments or competition information that will assist us in properly preparing your quote. Δ Broker Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneFaxClient InformationClient Name First Last Date of Birth MM slash DD slash YYYY Risk Class Preferred Standard Rated HeightWeightHas applicant ever used tobacco? Yes No Specify type & date of last useMedicationsMedical HistorySpouse Name First Last Spouse Date of Birth MM slash DD slash YYYY Spouse Risk Class Preferred Standard Rated HeightWeightHas applicant ever used tobacco? Yes No Specify type & date of last useSpouse MedicationsSpouse Medical HistoryState of ResidenceSelect A StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBenefit AmountIs this benefit amount: Daily Monthly Marital Status Married Single Elimination Period (days) 30 60 90 180 365 Benefit Period (years)Select One234567810InflationSelect OneNone5% Simple3% Compound5% CompoundFuture Purchase OptionConsumer Price IndexHome Care 50% 75% 100% Non-Forfeiture Benefit Yes No HHC Waiver? Yes No Shared Care Yes No Payment OptionsSelect OneAnnualSemi-AnnualQuarterlyMonthlyAre you in competition for this case? Yes No Additional OptionsComments Δ Broker InformationAgent Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Email* Phone*Fax*Client InformationName* First Last Birthdate*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female State*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificTobacco History*NoneCigarettesCigarPipeSmokelessCurrent or date of last use:Annual Income*BonusesOccupation / DutiesBusiness Owner Yes No What type of business?Years of Ownership?Total Average Monthly ExpensesPlan Design InformationPlease complete for at least 1 plan typePlan Type - Personal: Elimination PeriodSelect14306090180360730Plan Type - Personal: Benefit PeriodSelect6 Months1 Year2 Years5 YearsTo Age 65To Age 67To Age 70Plan Type - Business Overhead: Elimination PeriodSelect306090Plan Type - Business Overhead: Benefit PeriodSelect365 Days18 Months24 MonthsMonthly BenefitPlease choose at least one optionDesired Amount $Quote Maximum Yes No Premium Mode Annual Semi-Annual Quarterly Monthly Optional Benefits / RidersCost of Living Adjustment? Yes No Return of Premium? Yes No Accidental Death? Yes No Guaranteed Insurability Option Rider? Yes No Activities of Daily Living? Yes No Additional comments, health concerns or benefits? Δ
