Agent Info:

    Name:      

    Agency:     

    Address:    

    City:               State:      Zip:      

    Phone #:         Fax #:

    e-mail address: 

General Information:

    Clients Name:     DOB:  

    Sex:   Male Female      Issue state:      Smoker:   Yes No

    Exact Occupation and Duties:  

    If in Sales, Percentage of Travel:   

    Income for the last two years:   Last Year:      

                                                        2 Years ago:   

If a business owner:

    Percentage of Manual Duties:           Number of Employees:  

   Number of Years in Business:             Works from:                   N/A Home Office

Disability Policy Request Information:

   Policy Form:    Individual BOE Buy-Sell Key Person       Elimination Period:   30 Day 60 Day 90 Day 180 Day 365 Day 18 Month 730 Day     

Not so fast, say the term lifers. The only reason to have fast life insurance is to replace the lost income of a family member who dies, and then only when the spouse or family is dependent on that income. If you are single with no dependents and no debts fast life insurance . If you are married and your spouse works, you probably do not need fast life insurance, either, assuming your spouse makes enough to support himself or herself.

Special Requests and Health Problems:

   Special Requests:  

   Health Problems: