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Client Information
Client Name:
Client / Owner State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist. Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
NY Non-Bus
NY Business
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Guam
Puerto Rico
Virgin Islands
American Samoa
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.
Medical History:
Quote 2 Applicants:
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.
Medical History:
Policy Information
Benefit Amount:
Daily
Monthly
Benefit Length:
3 year
4 year
5 year
6 year
10 year
Lifetime
Waiting Period:
30 Days
60 Days
90 Days
180 Days
Inflation Option:
5% Simple
5% Compound
GPO
Riders:
Waiver Elimination HC
Restoration of Benefits
Nonforfeiture
Shared Care
Survivorship Waiver
Agent/Broker Information
Your Name:
Your Phone:
Your Email:
