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Life, Annuities, LTC, Life and Annuity Settlement
    
    
    
    
    
    
    

"If a man doesn't believe in life insurance, let him die once without it. That will teach him a lesson." - Will Rogers

* Full Name of Agent
Address Line 1
Address Line 2
City, State, Zip
* E-Mail
* Business Phone
Cell Phone
Home Number
Fax Number

Applicants Name:
Date of Birth:
Sex:
Male
Female

Requested Carrier/Product (if any)
State
Amount of premium available
The source this premium comes from: (cash, IRA, 1035, CD)
Premium Type
Qualified
Non-Qualified
Any surrender period requirements?
Cost Basis
Will monthly income be needed?
Yes
No
If yes, please specify:
How often would the income need to be paid?
Annual
Semi-Annual
Quarterly
Monthly
These income payments would need to begin when?
When will funds be available for this case?

Are you in competition for this case?
Yes
No
I don't know
If yes, please specify:
Any additional comments?
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