INDIVIDUAL LIFE INSURANCE PROPOSAL REQUEST
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?
Reason:
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
john@brassringfinancial.solutions
888-651-0025
We will provide you the best quotes from the industry’s leading carriers.