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Permanent Life Questionnaire SECTION I: AGENT INFORMATION * Full Name of Agent Address Line 1 Address Line 2 City, State, Zip * E-Mail * Business Phone Cell Phone Home Number Fax Number SECTION II: CLIENT INFORMATION Applicants Date of Birth: Applicants Name Applicants sex: Male Female Does the applicant use tobacco? None Cigarette Cigar Chew Quote a preferred class on the applicant? Yes No SECTION III: CLIENT 2 INFORMATION Second Applicants Date of Birth: Second applicants name: Second Applicants sex: Male Female Does the second applicant use tobacco? None Cigarette Cigar Chew Quote a preferred class on the second applicant? Yes No SECTION IV: QUOTE INFORMATION State of quote: Primary objective: Death Benefit Cash Accumulation Guarantees Low Premium Face amount(s): Specified carrier: SECTION V: PRODUCT INFORMATION Whole Life? Single Premium Full Pay Term? ART 5 10 15 20 25 30 Permanent? UL Survivor UL VUL SVUL Permanent - Desired Interest Rate: Permanent - Alternate Interest Rate: Payment options Annual Semi-Annual Quarterly Monthly SECTION VI: SUSPEND PAY Suspend Pay - Cash value: Suspend Pay - At age: Suspend Pay - Years: SECTION VII: PAYMENT PLANS Payment Plans - 1035 Exchange: Payment Plans - Lump Sum: SECTION VIII: RIDERS Riders - Child Rider: Riders - Waiver of Premium: Yes No Riders - ADB: Yes No SECTION IX: CASE INFORMATION Are you in competition for this case? Yes No I don't know If yes, please specify: Additional comments or health concerns?