Name: 
Phone #:  ()-
State:  CA AZ VA

Amount of life insurance needed:

• For a limited period of years:  $
  For a limited period of years:  $
  For a limited period of years:  $
  Would you like money back from your limited period life insurance in case you don't die during that time (It would cost more.)?  Yes   No
• For a permanent period (a permanent policy may build up cash value ):  $

How important are guarantees to you (stronger guarantees cost more.)?

• Price guarantee for as long as possible:
  Very important:
  Somewhat important:
  Not too important:
  
• Reasonable level of cash value build up guarantee:
  Very important:
  Somewhat important:
  Not too important:
  

Date of birth:  Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  , 19

Sex:  Male Female

Do you smoke?  Yes No
If no, have you quit smoking in the last three years?:  Yes No

Height:  feet, inches.
Weight: 

Health status and medicines you take: 

Tax bracket:  15%, 28%, 31%, 36%, 39.6%

When it comes to financial matters, are you a:
Big risk taker
Moderate risk taker
Minimum risk taker

Do you have a retirement account?:  Yes,   No

Do you have an emergency fund?:  Yes, No

What is your approximate net worth (value of what you own, minus what you owe):  $

List any dangerous duties or hobbies: 

Do you have any property that you expect to leave as an inheritance to your children, grandchildren, or charity?:  Yes, No
Do you meanwhile need that money or property for generating income to you?:  Yes, No

Please note:  The answers you provide in this form may affect the cost of your life insurance policy, should you obtain one.  But if any of these responses are less than truthful, it may seriously jeopardize your coverage.  When completing application information, we are obligated to pass on the information to the insurance company as it has been stated to us.