test

TBI/BBA Drop Ticket

Step 1 of 3

33%

PROPOSED INSURED INFORMATION
Name*
First Last
Date of Birth*
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
- Pacific Life
- Protective
- Prudential
- SBLI
Face Amount:*
Level Premium Period:*
- 10 year level term
- 15 year level term
- 20 year level term
- 25 year level term
- 30 year level term
- Universal Life
- Whole Life
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:*
MM slash DD slash YYYY
Beneficiary:
- Primary
- Contingent
% Share
Relationship:
SS#:
Date of Birth:
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:*