Your Contact InformationAgent First NameAgent Last NameAgent PhoneAgent Email About the ClientClient Name(Required) First Last Date of Birth MM slash DD slash YYYY Gender(Required)-MaleFemaleState 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 Height(Required)UnknownLess than 4'5"4'5''4'6''4'7''4'8''4'9''4'10''4'11''5'0''5'1''5'2''5'3''5'4''5'5''5'6''5'7''5'8''5'9''5'10''5'11''6'0''6'1''6'2''6'3''6'4''6'5''6'6''6'7''6'8''6'9''6'10''6'11''More than 6'11"Weight (lbs.)(Required)-UnknownLess than 90 lbs90919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350More than 350 lbsEnter WeightAny weight loss/gain in the last 12 months?-NoYesGain or Loss & Amount?(Required)Reason for Weight Gain/Loss?(Required)-Diet/ExerciseWeight Loss SurgeryWeight Loss Drugs (Ozempic, etc.)Other (Provide details in Additional Case Details section, below.)Date last seen by a Physician? Month Day Year Reason seen?Tobacco Usage?(Required)-NeverCurrentFormerType(Required)-UnknownCigaretteCigarPipeNicotine Patch/GumHookahZynnBetelnutOtherFrequency(Required)-UnknownDailyWeeklyMonthlyQuantity(Required)If Former, provide date of last usage:(Required)If Other, Please Indicate type of tobacco below.(Required)Product & Case Design DetailsFace Amount(Required)Offer Needed to Place(Required)-Preferred BestPreferred PlusPreferredPreferred TobaccoStandard PlusStandardStandard TobaccoTable 2Table 2 TobaccoTable 3Table 3 TobaccoTable 4Table 4 TobaccoTable 5Table 5 TobaccoTable 6Table 6 TobaccoOtherIf Other, please indicate the offer/rating needed to place below:*(Required)Product Type Term Insurance Accumulation IUL Protection IUL Accumulation VUL Protection VUL Guaranteed UL Whole Life Survivorship Asset-Based LTC Other Riders Riders Long-Term Care Chronic Illness - Premium Charge Chronic Illness - Inherent Waiver of Policy Charges Waiver of Specified Premium Other If Other, please indicate the Product type below:If Other, please indicate Rider type belowCarrier SelectionUnderwriter discretion means you are seeking the best possible offer regardless of carrier. Underwriter Discretion ANICO Corebridge Equitable F&G Foresters John Hancock Legal & General Lincoln MassMutual Mutual of Omaha Nationwide New York Life North American OneAmerica Principal Protective Prudential Sagicor Securian Symetra Transamerica Other If Other, Please Provide Carrier(s) of interest: Carrier 1Carrier 2Carrier 3Carrier 4Medications & DosagesIs the Client currently taking any medications?-UnknownNoYesPlease list any current medications below. MedicationReason PrescribedDosagePlease list any current medications below. Underwriting IssuesPlease indicate the underwriting issue or issues below. Check all that apply!*(Required) Family History (History of Cancer, Cardiac or Stroke in an immediate family member.) Medical History (The Client's Personal Medical History) Personal History (Things like Military Service, Foreign National/Residence/Travel, Bankruptcy, etc.) Avocations (Scuba Diving, Private Aviation, etc.) Other (If Other, please summarize the issue in the Additional Case Details section below.) Family HistoryPlease provide any Family History Details below: RelationshipHistory TypeAge of DiagnosisAge at Death, if applicableMedical HistoryMedical Impairments: Select All that Apply(Required) Alcohol Usage Aneurysm Anxiety Arthritis Asthma Atrial Fibrillation BRCA Positive Test Cancer, Bladder Cancer, Breast Cancer, Cervical Cancer, Colorectal Cancer, Leukemia Cancer, Lymphoma Cancer, Other Cancer, Ovarian Cancer, Prostate Cancer, Skin Cancer, Testicular Cancer, Thyroid Cardiomyopathy Carotid Artery Disease Chronic Kidney Disease Colon Polyps COPD Coronary Artery Disease Crohn’s Disease Depression Diabetes Drug Usage Epilepsy Hemochromatosis Hepatitis Hyperlipidemia Hypertension Kidney Transplant Liver Tests Lupus Multiple Sclerosis Pacemaker Parkinsons Disease Polycystic Kidney Disease Proteinuria Sarcoidosis Sickle Cell Anemia Sleep Apnea Stroke and TIA Ulcerative Colitis Valve Disease (Including Surgery) Weight Loss Surgery Other (Provide details below.) Please provide any additional specifics in the Additional Case Details section, below. Personal HistoryPersonal History: Select all that Apply:(Required) Active Duty Military Criminal History Driving History DUI Financial Underwriting/Bankruptcy Foreign National Foreign Residence Foreign Travel Other (Provide details in Additional Case Details section, below.) Please provide any additional specifics in the Additional Case Details section, below. AvocationsAvocations: Select All that Apply:(Required) Aviation Climbing Racing Scuba Sky Sports Other (Provide details in Additional Case Details section, below.) Medical History & Medication DetailsPlease provide the specifics of the client's medical history below.Supporting DocumentationSupporting Documents Drop files here or Select files Max. file size: 256 MB. Please upload any additional documentation relevant to the case here.
