FAST AND EASY LIFE INSURANCE PROPOSAL FOR BUSY PEOPLE

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FIRST NAMEFirst Name

LAST NAME

Dateof appointment

Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

Countyyour county

PHONECELL PHONE#

Emaila valid email

Email again for Accuracya valid email

Married ?

YesNo

Currently Insured ?

YesNo

If yes, List company, # years, and if Term or Univeral Life?your full name

What is your Occupation? (Also list your spouses occupation if married.)

UNDERWRITING INFORMATION

First Name of Insured

Last Name of Insured

Sex

SEX?MaleFemaleOther

Birthdate of Insuredyour full name

Do you smoke

Smoke ?YesNo

Height of Insured

Weight in 1lbsyour full name

Describe any Health issues last 5 yrs. If none type "None"

Describe any and all Medications taken. Please list the amounts and frequency taken. If none type "NONE"your full name

Life Face Amount

AMOUNT OF COVERAGE ?$75,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$750,000$1,000,000$2,000,000$5,000,000

Type of Coverage

TYPE OF COVERAGE ?TermMortgage ProtectionUniversal LifeIndex Universal Life

Years of Level Premium, If Termpick one!

Years Level if selecting Term10 Year Guaranteed20 Year Guaranteed30 Year GuaranteedTerm not Selected

DESCRIBE YOUR REASONS FOR BUYING LIFE INSURANCE. ALSO DESCRIBE WHY YOU SELECTED THE TYPE OF COVERAGE YOU SELECTED ABOVEmore details

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