Broker Name_________________________________

Affiliation: __________________________________

Telephone # (      )___________ Fax # (      )______________

Email Address______________________________________________

City, State,  Zip____________________________________________________

Illustration to be received by: Mail____ Fax____ Email____

Client Name: __________________________________________ D.O.B. ________________________

Sex: □ M □ F Tobacco Use: □ Y □ N Type of Tobacco: ________ Date of last use:__________

State: _______ Net Annual Income: ________________ Occupation_____________________________

Face Amount:____________________________________________________________________________

Approximate __________ Height _______ Weight ________

Estimated Rate Class:
___ Preferred Best Non Nicotine
___ Preferred Non Nicotine Type of Tobacco:
___ Standard NoNicotine Preferred Nicotine Use
___ Standard Nicotine Use
Type of Insurance: Term _______ Length of Term coverage_____# of Years

WL ______ UL _____ Final Expense ____Simplified Issue _____

Has proposed insured been hospitalized or had medical treatment in the last 5 years?
Medications: ___________________________________________________________________
Has proposed insured ever been treated for stroke, heart disease, coronary disease
cancer, kidney disease or lung disorder? If yes, provide details:
Family History: Any immediate family member died/diagnosed before age 60 of/with
stroke, cancer, coronary disease or kidney disease? If yes, please give details:
COMMENTS: ________________________________________________________________________

Please submit the Life Quote information via email:

John C. Massolio III, CLU ChFC


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