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

    Class:  Preferred    Select     Standard    Rated     

    Qualified         Non-qualified      

    Company:  State Life Unim CNA Allianze Fortis AIG

   Premium mode:   Annual Semi-annual Quartrtly Monthly W/D    Premium duration:    Lifetime 10 Payment Single Payment

Policy Information: 

Long Term Care:

    Reimbursement:            Indemnity:    

   Elimination Period:   0 7 14 20 30 90 60 100 120 180         Benefit Period:   Lifetime 6 year 5 year 4 year 3 year 2 year 1 year     

Nursing Home:  

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.

Home Health Care:   Yes No

    (pick 1&2 or 3)

   1. Elimination Period:   N/A 0 7 14 20 30 90 60 100 120 180     2. Benefit Period:   N/A Lifetime 6 year 5 year 4 year 3 year 2 year 1 year  

    3. Home Health Care Policy Maximum:   N/A 100% 80% 60% 50%

   HCBC Health Care Waiver:   Yes No    HCBC Enhancement Rider:   Yes No   

Riders:

    Inflation Protection:   None CPI 5% Simple 5% Compounded   Indemnity Rider:   Yes No

    Non Forfeiture Feature:   Yes No    Survivorship Waiver:   Yes No

Health History:

    Health problems including medications: