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BBA EZLife
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PROPOSED INSURED INFORMATION
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
SSN:
*
Gender
*
Male
Female
Physical Address
*
City
*
State
*
Zip code
*
State of Birth:
*
Drivers License #:
*
State Issued:
*
Preferred Phone:
*
Evening Phone:
*
Cell:
*
Best date to contact:
*
Best time to contact:
*
Proposed Insured Email Address:
*
Occupation:
*
Is Proposed a US Citizen:
*
Yes
No
Is the owner other than the Proposed Insured ?
*
YES
NO
If so, Full Name
Date of Birth
Social Security Number
Address
Relationship:
Will there be a Payor other than the insured ?
*
Yes
NO
If yes, Full Name
Date of Birth
Social Security Number
Address
Relationship:
POLICY INFORMATION
Carrier:
*
American General
Banner
John Hancock
Mutual of Omaha
Protective
Pacific Life
SBLI
Benefit Amount:
*
Level Premium Period:
*
10 year level term
15 year level term
20 year level term
25 year level term
30 year level term
Product Name:
Premium Quoted:
*
State of Sale:
*
Policy Delivery State:
*
Rate Class Quoted:
*
Premium Mode:
*
Annual
Semi-Annual
Quarterly
Monthly Draft
Optional Riders:
Children’s Insurance
Waiver of Premium
Acc Death Benefit
If selecting Childrens Ins - How Much?
If selecting Acc Death Benefit - How Much?
Any other existing insurance or annuities:
*
Yes
No
Will it be replaced:
*
Yes
No
Name of current carrier:
Policy #:
Date of issue:
Amount of current coverage:
Does the Owner want the policy delivered electronically?
*
Yes
No
Email Address
*
Purpose of insurance:
*
Income Replacement
Family Protection
Debt Replacement
Other
BENEFICIARY INFORMATION
Beneficiary:
*
Primary
Contingent
% Share
*
Relationship:
*
SS#:
*
Date of Birth:
*
Date Format: MM slash DD slash YYYY
Beneficiary:
Primary
Contingent
% Share
Relationship:
SS#:
Date of Birth:
Date Format: MM slash DD slash YYYY
FINANCIAL INFORMATION
Gross Annual Income:
*
Household Income (if gross income is zero):
*
Total Assets:
*
Total Liabilities:
*
Has the proposed insured had any life insurance declined, postponed or offered other than applied for:
*
Yes
No
Has proposed insured ever used tobacco in any form:
*
Yes
No
What Type:
*
Last Used:
0 to 12 months
in the last 12 to 18 months
18 to 24 months
24 to 36 months
36 to 60 monthls
Is proposed insured taking any prescription medications:
*
Yes
No
If so, list in additional remarks.
Does the proposed insured have a history of alcohol or substance abuse:
*
Yes
No
Any DUIs or DWIs in the past:
*
5 years
3 years
none
Has the proposed insured had more than two motor vehicle moving violations in the past three years:
*
Yes
No
Has either parent or sibling had a history of cardiovascular disease or cancer before age 60:
*
Cardio
Cancer
none
Has either parent died as a result of cardiovascular disease or cancer before age 60:
*
Cardio
Cancer
none
Have both parents died as a result of cardiovascular disease before age 60:
*
Yes
No
PROPOSED INSURED HISTORY - CONTINUED
What is the proposed insured’s:
Height:
*
Weight:
*
Does the proposed insured participate in any hazardous activities, such as piloting an aircraft, scuba diving, motor vehicle racing, etc? If so, please give details:
*
Does the proposed insured plan to travel outside of the US any time in the near future?
Where:
When:
How Long :
ADDITIONAL REMARKS
AGENT INFORMATION
Agent Name:
*
Share of Commissions:
*
Phone #:
*
Email Address:
*
Agent Name:
Share of Commissions:
Phone #:
Email Address:
How long have you known the proposed insured:
*
Are you related
*
Yes
No
Date completed:
*
Please hit submit at the bottom of this page to complete Drop Ticket
Any additional remarks?
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