Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Home Phone:   
  Work Phone: 
 
  
  Insured 1:
     Male          Female
    Date of Birth: 
     Non-Smoker    Smoker
  
  
  Insured 2:
     Male          Female
    Date of Birth: 
     Non-Smoker    Smoker


  Has either proposed insured experienced any serious health-related problems?
     Yes    No

  Has either proposed insured ever been rated or declined for an insurance policy?
     Yes    No

  If yes, please explain:
    

  I prefer quotes for a:
     Fixed Yield Policy    Variable Yield Policy

  Desired face (death benefit) amount: 

  Your estimated time frame to secure such a plan is?
     Less than one month    1 to 3 months    3 to 6 months

  Your general awareness on this subject is:
    NoneLowMediumHighVery High 

  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
    NoYes

  Additional Comments/Questions: