Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Home Phone:   
  Work Phone: 
  
  Your date of birth:     
     Non-Smoker   Smoker

  Spouse's date of birth: 
     Non-Smoker   Smoker
  
  Would this be a Single Insured or Joint Insured policy?
     Single    Joint

  Do you currently own insurance?            Yes   No

  Are you looking to upgrade this policy?    Yes   No
  
  Your tax bracket is:
     28%    31%    36%    39.6%    Unknown
  
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  

  Amount you may want to consider investing: 
     Single    Quarterly    Semi-Annually    Annually

  For how many years (5 years minimum): 

  Your estimated time frame to purchase a universal life policy 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: