Use this form for Whole, Term and Child Life Insurance

Personal Information                                                       * Required Fields
	* Your Name:
	* Your Address:
	* City:
	* State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New York New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wyoming Wisconsin Washington D.C.
	* Zip Code:
	* Phone Number:		-
	Work Phone Number:		-   Ext.
	* Best time to contact you:		Select Morning / Home Morning / Office Afternoon / Home Afternoon / Office Evening / Home Evening / Office
	* Your E-mail Address:
General Information
	* Your Gender:		Choose One Male Female
	* Your Date of Birth:		Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
	* Your Height:		-- Feet -- 4 Feet 5 Feet 6 Feet 7 Feet -- Inches -- 0 Inches 1 Inches 2 Inches 3 Inches 4 Inches 5 Inches 6 Inches 7 Inches 8 Inches 9 Inches 10 Inches 11 Inches
	* Your Weight:
	* Marital Status:		Choose One Single Single-Parent Married Separated Divorced Widowed
		Spouse's Full Name:
		Spouse's  Date of Birth:	Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
	* DUI in the past 7 years?		Yes No
	* Have your driving privileges been suspended or revoked in the past 7 years?		Yes No
	* Been convicted of 2 or more moving violations in the past 3 years?		Yes No
	* Ever been convicted of, or are now awaiting trial for a felony?		Yes No
	* In the past 5 years, have you filed for bankruptcy?		No Yes
	* Are you a United States Citizen?		Yes No
Work Information
	* Occupation:
	* How Many Years at this Occupation:
	* Exact Duties:
	* % of your work that requires travel:
	Do you work out of your home?		Yes No
	If so, what % of time is in the home?
	Government Employee?		Yes No
	Business Owner?		Yes No
	If so, what % ownership?
	Number of employees?
	Type of Company?		Sole Proprietor Corporation - C Company - LLC Partnership S-Corporation
	* Are you a private pilot or student pilot?		Yes No
	If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.)
Policy Information
	* Other Life Insurance in Force?		Yes No
	Amount of  Group Life:
	- Coverage paid for by?		Self Employer
	- Current Insurance Carrier?
	Amount of Individual Life Insurance?
	Term/Whole Life/Both?
	Current Insurance Carrier?
	Who is paying for new premium?		Self Employer
	Would the intention of this policy be to replace any existing policy's?		Yes No
	* Life insurance Amount and Type:		50,000 100,000 200,000 250,000 300,000 400,000 500,000 750,000 1,000,000 2,000,000 3,000,000 30-Year Guaranteed Level Premium Term 20-Year Guaranteed Level Premium Term 15-Year Guaranteed Level Premium Term 10-Year Guaranteed Level Premium Term Universal Life Whole Life Variable Life Other
	- Additional Quote:		Select 50,000 100,000 200,000 250,000 300,000 400,000 500,000 750,000 1,000,000 2,000,000 3,000,000 --------------- Select --------------- 30-Year Guaranteed Level Premium Term 20-Year Guaranteed Level Premium Term 15-Year Guaranteed Level Premium Term 10-Year Guaranteed Level Premium Term Universal Life Whole Life Variable Life Other
	- Additional Quote:		Select 50,000 100,000 200,000 250,000 300,000 400,000 500,000 750,000 1,000,000 2,000,000 3,000,000 --------------- Select --------------- 30-Year Guaranteed Level Premium Term 20-Year Guaranteed Level Premium Term 15-Year Guaranteed Level Premium Term 10-Year Guaranteed Level Premium Term Universal Life Whole Life Variable Life Other
	Guaranteed Renewable Option? This will allow you to renew  the policy beyond the termination date.		Yes No
	Accidental Disability Rider Waiver of Premium if you become disabled		Yes No
	Child Life Rider		Yes No
		Child Life Amount	none 1,000 2,000 3,000 4,000 5,000 6,000 8,000 9,000 10,000
*Do you participate in any "extreme" sporting activities? i.e. Scuba Diving, Rock Climbing, Hang Gliding etc.....			No Yes
		If Yes, please specify:
	* State of Residency:
	* State of Application:
Medical Information
* Have you had a complete routine     Health exam within the past 2 years?			No Yes
*Are there any health issues or preexisting conditions?			No Yes
		If Yes, please specify:
	* Do you take any prescription medications?   No Yes
		If Yes, please specify types and dosage:
* Tobacco Usage:			Non Smoker Under 1 Year 1 to 2 years Over 2 years
* Have you smoked in the past 12 months:			Select NO YES
* Do you use other tobacco products:			Select NO YES
	Check all that apply
	cigars  pipe chewing tobacco nicotine gum 'The Patch'
	Additional Comments: