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Client Information
Client Name:
Age /
Date of Birth:*
Male
Female
Smoking Status:
Never used tobacco or nicotine Products.
Used tobacco or nicotine products, quit for less than 1 year.
Used tobacco or nicotine products, quit for 1-2 years.
Used tobacco or nicotine products, quit for 3 or more years.
Smokes a pipe.
Smokes cigars.
Chews tobacco.
Uses the patch or Nicorette.
Occupation:
Salary:
Medical History:
Policy Information
Monthly Benefit:
Benefit Length:
2 year
5 year
10 year
Age 65
Age 67
Waiting Period:
30 Days
60 Days
90 Days
180 Days
365 Days
Riders:
SIR
COLA
Residual/Partial
FIO
Catastrophic
Agent/Broker Information
Your Name:
Your Phone:
Your Email:
