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Step 1 of 5 - Get Started

Complete the information below for each life insurance policy you own. Options are available for individual and survivorship. You may add up to five policies. If you have more than five, please enter the ones with the highest value.

Number of Policies*

POLICY 1*

Is this policy an individual policy (insures one life) or a survivorship policy (insures two lives, also known as a second-to-die)?

Survivorship Policy Type*

Individual Policy Type*

Policy Nickname

What your current death benefit range?

What is your policy’s cash value range?

What is your annual premium payment range?

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What is your approximate annual premium payment?*

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What is your approximate current death benefit?*

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What is your policy’s approximate cash value?*

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Which insurance company issued your policy?*

About how long have you had your policy?*

POLICY 2

Is this policy an individual policy (insures one life) or a survivorship policy (insures two lives, also known as a second-to-die)?

Individual Policy Type

Survivorship Policy Type

Policy Nickname

What your current death benefit Range?

What is your policy’s cash value Range?

What is your annual premium payment Range?

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What is your annual premium payment?

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What is your policy's cash value?

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What is your Current Death Benefit?

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Which insurance company issued your policy?

About how long have you had your policy?

CONTACT INFORMATION

Please provide the information for the person completing this form.

Name*

First Last

Address

Street Address City State ZIP Code

Email*

Phone

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BMI 1

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BMI 2

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BMI 3

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BMI 4

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BMI 5

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BMI 6

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BMI 7

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BMI 8

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BMI 9

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BMI 10

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BMI Score 1

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BMI Score 2

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BMI Score 3

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BMI Score 4

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BMI Score 5

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BMI Score 6

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BMI Score 7

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BMI Score 8

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BMI Score 9

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BMI Score 10

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BMI Score Total

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Insurance Score 1

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Insurance Score 2

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Insurance Score

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Annual Premium 1

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Annual Premium 2

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Annual Premium Total

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When did you purchase the Policy 1

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When did you purchase the Policy 2

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When did you purchase the Policy Total

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Age Score 1

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Age Score 2

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Age Score 3

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Age Score 4

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Age Score 5

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Age Score 6

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Age Score 7

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Age Score 8

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Age Score 9

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Age Score 10

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Age Score Total

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Death benefit 1

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Death benefit 2

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Death benefit total

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Cash value 1

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Cash value 2

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Cash value Total

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Policy Type

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Tobacco Total

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Health Total

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Basic Score

Number of Policies: {Number of Policies:106}

Policy 1 Review

Individual or Survivorship?: {POLICY 1:107}

Policy Type: {Survivorship Policy Type:138}{Individual Policy Type:24}

Policy Nickname: {Policy Nickname:108}

Current Death Benefit: {What is your current death benefit?:44}

Annual Premium Payment: {What is your annual premium payment?:152}

Policy Cash Value: {What is your policy\'s cash value?:45}

Policy Purchase Date: {When did you purchase your policy?:151}

Policy Insurer: {Which insurance company issued your policy?:38}

About Insured

Name: {Name (First):110.3} {Name (Last):110.6}

Gender: {Gender:111}

Age: {Age:52}

Weight: {Weight (lbs.):21}

Height: {Height:41}

Tobacco/Nicotine/Cannabis Usage: {Based on the chart below, in the past two years, have you used any tobacco, nicotine, or cannabis products?:182}

Health Status: {Based on the chart below, how is your health?:350}

About Insured #2

Name: {Name (First):148.3} {Name (Last):148.6}

Gender: {Gender:176}

Age: {Age:141}

Weight: {Weight (lbs.):142}

Height: {Height:143}

Tobacco/Nicotine/Cannabis Usage: {Based on the chart below, in the past two years, have you used any tobacco, nicotine, or cannabis products?:183}

Health Status: {Based on the chart below, how is your health?:351}

Policy 2 Review

Individual or Survivorship?: {POLICY 2:119}

Policy Type: {Survivorship Policy Type:120}{Individual Policy Type:156}

Policy Nickname: {Policy Nickname:121}

Current Death Benefit: {What is your current death benefit?:122}

Annual Premium Payment: {What is your annual premium payment?:155}

Policy Cash Value: {What is your policy\'s cash value?:124}

Policy Purchase Date: {When did you purchase your policy?:154}

Policy Insurer: {Which insurance company issued your policy?:125}

About Insured

Name: {Name (First):130.3} {Name (Last):130.6}

Gender: {Gender:131}

Age: {Age:132}

Weight: {Weight (lbs.):133}

Height: {Height:134}

Tobacco/Nicotine/Cannabis Usage: {Based on the chart below, in the past two years, have you used any tobacco, nicotine, or cannabis products?:184}

Health Status: {Based on the chart below, how is your health?:352}

About Insured #2

Name: {Name (First):185.3} {Name (Last):185.6}

Gender: {Gender:187}

Age: {Age:188}

Weight: {Weight (lbs.):189}

Height: {Height:190}

Tobacco/Nicotine/Cannabis Usage: {Based on the chart below, in the past two years, have you used any tobacco, nicotine, or cannabis products?:191}

Health Status: {Based on the chart below, how is your health?:353}

Contact Information

Name: {Name (First):93.3} {Name (Last):93.6}

Address: {Address (Street Address):3.1} {Address (Address Line 2):3.2}

{Address (City):3.3}

State: {Address (State / Province):3.4}

Zip: {Address (ZIP / Postal Code):3.5}

Country: {Address (Country):3.6}

Email: {Email:7}

Phone: {Phone:6}

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Get Started (continued)

Policy 1

Insured Information #1

Insured Information

Insured Information #2

Policy 2

Insured Information #1

Insured Information

Insured Information #2

CONTACT INFORMATION

Policy 1 Review

About Insured

About Insured #2

Policy 2 Review

About Insured

About Insured #2

Contact Information