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Producer information
Name
First Last
Email

Client Information
Name
First Last
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
State
Height ft./in
Weight lbs.
Tobacco
- Non Smoker
- Cigarettes
- Patch
- Cigars
- E-cig
- Marijuana
- Chewing Tobacco
- Pipe
- Nicotine gum
- If yes, how often?
How often?*
Second Insured
- Second Insured
Name
First Last
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
State
Height ft./in
Weight lbs.
Tobacco
- Non Smoker
- Cigarettes
- Patch
- Cigars
- E-cig
- Marijuana
- Chewing Tobacco
- Pipe
- Nicotine gum
- If yes, how often?
How often?*

Insurance Information
Life
- Guaranteed UL
- Survivorship UL
- Whole Life
- Indexed UL
- Term
Choose the term:
- 10
- 15
- 20
- 30
Disability
- Individual
- Business overhead
Linked Benefit
- Lincoln Money Guard
- Nationwide Care matters
- One America Asset Care
Benefit amount
Desired premium
Solve for maximum accumulation
- Yes
- No
Solve for DB guarantee
- Yes
- No
Lifetime Guarantee
Age 100 Guarantee
Guarantee to age
- 85
- 90
- 95
- 105
- 110
Premium Mode
- Monthly
- Quarterly
- Semi-Annual
- Annual
- 1035
- Lump Sum
- Short pay – 10,15,20 or other
- Life pay
1035 Amount
Lump Sum Amount
Short Pay Amount
Riders
- Long Term care
- Chronic Illness
- Waiver of premium
- Children’s insurance
- Vitality (only available with John Hancock)
- Other
Distributions: Maximum starting at retirement (age 65)
- Yes
- No

Medical Information
Total Cholesterol (example 210)
Cholesterol Ratio (example 4.5)
Blood pressure

Additional Medical information
Any conditions
Medications

Family History
Immediate Family members (parents or siblings) treated for
- Cancer
- Cardiovascular disease
- Diabetes
- Stroke or TIA
Hazardous Avocation
- Scuba
- Aviation
- Motor Sports
- Parachuting
- Other
- If yes give details
Motor Vehicle Record
- DWI
- Moving Violation
- DUI
- Reckless Driving
- Suspended License
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