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1 Client Info
2 Medical Info
3 Lifestyle
4 Beneficiary
5 Existing Insurance
6 Product Info
Client Information
US Citizen?
Is there a second insured?
Second Insured
Owner Information
Will the insured be the owner?
Medical Information
Do you have health issues?
Any other doctors seen in last 5 years?
Have you ever had a life, health, or disability policy rated or declined?pick one!
Have you applied for life insurance within the last year?pick one!
Lifestyle Information
Do you plan to travel outside of the US in the next 2 years?pick one!
Do you plan to participate within the next 2 years, or have you participated within the last 2 years in; underwater diving; mountain climbing; aerial sports; auto, motorcycle, or boat racing; heli skiing; rodeo sports; boxing; equine sports; BASE jumping or wing diving?pick one!
Have you ever been convicted or are you awaiting trial for a felony?pick one!
In the last 5 years have you filed for bankruptcy?pick one!
Are you a member of the armed forces, reserves, or National Guard?pick one!
Do you have a history of drug or alcohol abuse?pick one!
Do you drink alcohol?pick one!
Beneficiary Information
Primary Beneficiary
Contingent Beneficiary
Existing Insurance
Is there existing insurance in force or pending?pick one!
Policy 1
Replacing
Type of Insurance
Policy 2
Replacing
Type of Insurance
Policy 3
Replacing
Type of Insurance
Carrier and Agent Information
Are you the agent?pick one!
Are you related to the proposed insured?pick one!
Did you see the client during the sale?pick one!
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