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Application Request
Name
First
Last
Email
Carrier name
American General Life Insurance Company
AXA Equitable Life Insurance Company
Banner Life Insurance Company
John Hancock Life Insurance Company USA
John Hancock Life Insurance Company NY
Lincoln Life & Annuity Company of NY
Lincoln National Life Insurance Company
North American Co for Life and Health
Protective Life Insurance Company
Pruco Life Insurance Company
Pruco Life Insurance Co of New Jersey
ReliaStar Life Insurance Company
ReliaStar Life Insurance of NY
Transamerica Life Insurance Company
William Penn Life Insurance Co of NY
Product
Age of Client/Clients
Reason for coverage
Business insurance
Income replacement
Estate Planning
Owner
Individual
Business
Trust
State the business was solicited in
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State the owner lives in
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
1035 exchange
Yes
No
Replacing existing coverage
Yes
No
Riders
Long Term care rider
Accelerated DB
John Hancock Vitality
Children’s insurance rider
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