JLTexpress App Checklist Make sure your case is a good fit for our JLTexpress App process. Please contact Pat Baker if you have questions.
|
|
- Daniela Watts
- 6 years ago
- Views:
Transcription
1 JLTexpress App Checklist Make sure your case is a good fit for our JLTexpress App process. Please contact Pat Baker if you have questions. Pat Baker Pat@JLThomasCo.com Toll Free (800) Phone (216) Fax (216) Checklist Was this case quick quoted due to medical impairments? o If yes, this case is not a good fit and will not receive the offer. Does the client uses ? Is the owner and the proposed insured the same person? Is the proposed insured 18 years or older or under age 65? If you are unsure if the case is a good fit please review with Pat Baker or one of our Marketing Reps Chester Ave. Cleveland, OH sales@jlthomasco.com (800) t: (216) f: (216)
2 JLTexpress App How it Works 1. The broker completes the JLTexpress App and submits via or fax. At this point you are done the rest is followed up by the carrier and client. 2. Your client will conduct a phone interview and schedule their exam with the carrier. 3. The client s signature is obtained by either o Phone, or during the exam. 4. Once approved, you deliver the policy or if elected the policy can be e-delivered via . Carriers Available 1500 Chester Ave. Cleveland, OH sales@jlthomasco.com (800) t:(216) f:(216)
3 JLTexpress App Workflow Life Ticket AppAssist Voice Signature Express Order Ticket Agent Signs via Speed e-ticket Express App Agent Signs via Life Ticket Fast App Agent Signs TermAccel or LincExpress
4 Express APP for Life Insurance APPLICANT INFORMATION Date of Birth: Male Female Phone: SS#: Driver s License #: Address: City: State: ZIP Code: Years At Address: Country of Birth: State of Birth: Height : Weight: US Citizen: Employer: Occupation: History of Drug or Alcohol Abuse? Ever Used Tobacco? DUI in last 10 years? If Yes, Date last used and Type of Tobacco: More than 2 moving violations in last 12 months? Best Time to Contact Client: Morning Evening Afternoon Have any immediate family members been diagnosed or died before age 65 with Cancer/Heart Disease? PROPOSED POLICY INFORMATION Is the proposed insured a member of the armed forces? Past Member AIG Banner Lincoln MetLife Principal Protective Prudential United of Omaha SBLI Plan Name: Premium: Payment: Annual Semi-Annual Quarterly Monthly State of Sale: Any Pending Insurance? Face Amount: Temporary Insurance? Purpose of Insurance: Class Quoted: Save Age: Riders: Waiver of Premium Accidental Death Benefit Accelerated Benefit Rider Return of Premium Child Rider BENEFICIARY INFORMATION SSN or Tax ID: Relationship: D.O.B.: OWNERSHIP INFORMATION (IF DIFFERENT THAN PROPOSED INSURED) SSN or Tax ID: Relationship: D.O.B.: FINANCIAL INFORMATION Income: Assets: Liabilities: Net Worth: Bankruptcy: If yes, discharged? EXISTING COVERAGE Carrier Name Face Amount Replacement? Yr. Issued Has insurance been declined, postponed, and offered other than applied for in the last year? If yes, please explain:
5 PRODUCER INFORMATION First Name: Middle: Last: SSN: Phone: Did you see the client during the sale? Are you related to the proposed insured? Are you delivering the policy face to If Yes, How? face? Knowledge of proposed insured: Self Known well for years? Know Slightly Met Very Recently Other SECOND PRODUCER INFORMATION (IF APPLICABLE) COMMISSION % First Name: Phone: Last Name: COMPLETE ONLY IF APPLYNG TO BANNER/WILLIAM PENN Do you have a history of alcohol or substance (drug) abuse? Have you had any DUIs in the past 5 years? Have you had more than two moving motor vehicle violations in the past 3 years? Have you used any nicotine based products in the past 36 months? Has either parent or a sibling of yours had a history of cardiovascular disease before age of 60? COMPLETE ONLY IF APPLYING THROUGH PRINCIPAL ACCELERATED UNDERWRITING PROGRAM Are you currently applying or have you applied for life insurance within the last year? Have you taken an insurance exam within the last year? If previously underwritten by The Principal, coverage was approved Preferred or Super Preferred. *Disregard cancer of opposite sex except for colon cancer. Disregard cancer if pertains to only one family member, and insured has regular check-ups targeted at early diagnosis. Please completed form to ExpressAPP@JLThomasCo.com or fax to For assistance or questions call True False N/A Applicant is a U.S. citizen or permanent resident with no travel or hazardous locations. True False Stated blood pressure is less than 135/80. True False Total cholesterol is less than 240, and cholesterol HDL ratio is less than 4.5. True False If age 50 or greater, applicant has a primary care physician and evidence of routine physicals. True False N/A No parent of sibling death from cardiovascular disease, stroke or diabetes prior to age 60. True False No parent of sibling death from breast, colon, ovarian or prostate cancer prior to age 60.* True False No history of bankruptcy in the past five years. True False No history of DUI or reckless driving within past five years. True False No life, health or disability insurance has been rated, ridered, or declined. True False No prior informal requests to The Principal within the last 24 months True False No labs have been ordered or completed within the last 12 months for life or disability insurance. True False Does the proposed insured have disability insurance?
Informal Inquiry. Please fax, mail or this form to Berson-Sokol
Informal Inquiry Please fax, mail or email this form to Berson-Sokol 23500 Mercantile Road Suite C Cleveland, OH 44122 P: (216) 464-1542 T: (800) 543-6000 F: (216) 464-6522 www.berson-sokol.com This informal
More informationAGENT S GUIDE TO UNIVERSAL LIFE INSURANCE
The Cincinnati Life Insurance Company Life Insurance AGENT S GUIDE TO UNIVERSAL LIFE INSURANCE LifeHorizons Simplicity UL* Policy Form CLI-137 Table of Contents Introduction... 1 Product features... 2
More informationSeries. Rate Book and Product Guide. Term Life Insurance with Guaranteed Level Premiums C10, C15, C20, C25, & C30
C Series SM Rate Book and Product Guide C10, C15, C20, C25, & C30 Term Life Insurance with Guaranteed Level Premiums M-0024 (12/01/05) Policy Form #051131700 or #0411317WY For nt Use Only. Not For Consumer
More informationUnderwriting Guidelines
Independent Marketing Group Underwriting Guidelines from American National Insurance Company & American National Life Insurance Company of New York A Guide to Basic Information & Requirements Agent Agent
More informationUNDERWRITING GUIDE. Term Life Insurance. FOR AGENT USE ONLY. Not for use with consumers. Product availability, features and rates may vary by state.
UNDERWRITING GUIDE FOR AGENT USE ONLY. Not for use with consumers. Product availability, features and rates may vary by state. 15-178-01111 (11/17) Important Notice Underwriting Guide for Assurity Assurity
More informationUnderwriting Quick Reference Guide Life Products December 2015
Underwriting Quick Reference Guide Life Products December 2015 Policies issued by American General Life Insurance Company (AGL) FOR FINANCIAL PROFESSIONAL USE ONLY. NOT FOR PUBLIC DISTRIBUTION. American
More informationThe AppAssist Tele-Application Process. Banner Life Insurance Company and William Penn Life Insurance Company of NY
The AppAssist Tele-Application Process Banner Life Insurance Company and William Penn Life Insurance Company of NY Banner Life Insurance Company and William Penn Life Insurance Company of NY Tele-Application
More informationUNDERWRITING ESTIMATOR
CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS UNDERWRITING ESTIMATOR Reference Guide Prudential s Preferred Underwriting Preferred Underwriting Quick Ratings Estimar Physical Measurements-Male and Female
More informationUNDERWRITING ESTIMATOR
CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS UNDERWRITING ESTIMATOR Reference Guide Prudential s Preferred Underwriting Preferred Underwriting Quick Ratings Estimar Physical Measurements-Male and Female
More informationGeneral Underwriting Guidelines
General Underwriting Guidelines Fidelity & Guaranty Life is the marketing name of Fidelity & Guaranty Life Insurance Company issuing insurance in the United States outside of New York. Fidelity & Guaranty
More informationUNDERWRITING GUIDELINES
Whole Life UNDERWRITING GUIDELINES LifeScape For Agent use only. Product availability, rates and features vary by state. 16-163-01111 (Rev. 7/10) Underwriting and Limits Whole Life Underwriting Guidelines
More informationUnderwriting Guidelines
AGE AND AMOUNT REQUIREMENTS FACE AMOUNT 0 25,000 ISSUE AGES 0 17 18 39 40 50 51 60 61 70 71+ JUVENILE ** 25,001 50,000 JUVENILE ** 50,001 99,999 JUVENILE ** 100,000 249,999 JUVENILE ** 250,000 1,000,000
More informationPLUS: Protective Life Underwriting Solution
PLUS: Protective Life Underwriting Solution ENHANCED EZ-APP PLUS PLUS TELELIFE ELECTRONIC POLICY DELIVERY E-SIGNATURE For Financial Professional Use Only. Not for Use With Consumers. One size doesn t fit
More informationSimplified Issue Whole Life Guaranteed Issue Whole Life AGENT GUIDE
Simplified Whole Life Guaranteed Whole Life AGENT GUIDE www.unitedhomelife.com 800-428-3001 Whole Life Portfolio Five Products for ages 0 to 80 1. Simple yes/no applications. Affordable, guaranteed 2 coverage.
More informationRATES & PRODUCT FEATURES
RATES & PRODUCT FEATURES VantagePoint SM 15/20/30 TERM LIFE INSURANCE WITH RETURN OF PREMIUM Underwritten by First Colony Life Insurance Company Lynchburg, VA Genworth Life Insurance Company Lynchburg,
More informationField Underwriting Guide
Field Underwriting Guide Thank you for choosing Vantis Life. Your business and the applications you submit are very important to us. This Guide is designed to provide you with an easy-to-read reference
More informationHow our process works
PLUS: Protective Life Underwriting Solution ENHANCED EZ-APP PLUS PLUS TELELIFE ELECTRONIC POLICY DELIVERY E-SIGNATURE One size doesn t fit all when it comes to underwriting. PLUS is designed to underwrite
More informationLife Insurance Application
Life Insurance Application Product Name Type of Enrollment / Change: (check all that apply) New Application Increase Reinstatement Other ReliaStar Life Insurance Company Home Office: Minneapolis, Minnesota
More informationC PR. Comprehensive PLUS Financial Network Policy Review
A GUIDE AND UTILITIES TO ASSIST YOUR CLIENTS IN MAINTAINING LIFE INSURANCE COVERAGE TO MEET THEIR EVOLVING NEEDS WHAT IS? As an advisor, you can provide a valuable service for your clients by making sure
More informationIllinois Standard Health Employee Application for Small Employers
Illinois Standard Health Employee Application for Small Employers INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please
More informationGroup Term Life Insurance for The Missouri Bar 10-year level premium
Group Term Life Insurance for The Missouri Bar 10-year level premium For Missouri Bar members, their families and their employees About life insurance Life insurance provides basic protection for your
More informationGeneral Underwriting Guidelines
General Guidelines Fidelity & Guaranty Life is the marketing name of Fidelity & Guaranty Life Insurance Company, and in NY only, Fidelity & Guaranty Life Insurance Company of New York. Each Fidelity &
More informationPolicy Review Fact Finder
Life Insurance Policy Review Fact Finder CLIENT NAME: ADVISOR: Approved for consumer use and for use with the general public. This resource is provided to you by AimcoR Group, LLC Information in this report
More informationSecureLife Universal Life Insurance AGENT GUIDE FOR AGENT USE ONLY NOT FOR PUBLIC USE
AGENT GUIDE SecureLife Universal Life Insurance Flexible Premium, Adjustable Death Benefit Universal Life Insurance With No-Lapse Guarantee Provision FOR AGENT USE ONLY NOT FOR PUBLIC USE SECURELIFE: AN
More informationAccelerated Underwriting Requirements for Xpress & Xpress Plus
Accelerated Requirements for press & press Plus What is press? An underwriting program that is used to process applications for insured s age 65 or under and applying for a face amount of $249,999 or less
More informationUnderwriting guidelines for fully underwritten life insurance products
Life insurance (R-4/207) Allianz Life Insurance Company of North America guidelines for fully underwritten life insurance products Have your client schedule their personal history interview (PHI). Please
More informationt h e l if e i n s u r a n c e policy review
t h e l if e i n s u r a n c e policy review 52188 Van Dyke Avenue Suite 200 Shelby Township, MI 48316 t h e l i f e i n s u r a n c e policy review p r o g r a m Overview Life insurance is a dynamic and
More informationUnderwriting Guidelines
LIFE SOLUTIONS Underwriting Guidelines Lincoln TermAccel Level Term Not a deposit Not FDIC-insured May go down in value Not insured by any federal government agency Not guaranteed by any bank or savings
More information$100,000 to $249,999. $60,000 to $99,999 UHIV (CA, NJ, NY, FL, TX, DC) EXAM, EXAM, IRP, MVR EXAM, EXAM, SPEC,UHIV (CA, NJ, NY, FL, TX, DC) EXAM,
UNDERWRITING OVERVIEW Age and Amount Requirements The guidelines in the chart apply the amount applied for and any amount applied for in the past two For Survivorship coverage: Requirements are based on
More informationKANSAS CITY LIFE INSURANCE COMPANY. Underwriting Requirements Guide FOR AGENT USE ONLY. NOT FOR USE WITH MEMBERS OF THE PUBLIC.
KANSAS CITY LIFE INSURANCE COMPANY Underwriting Requirements Guide FOR AGENT USE ONLY. NOT FOR USE WITH MEMBERS OF THE PUBLIC. Amplified Includes blood profile as well as height, weight, blood pressure,
More informationUnderwriting Essentials
Underwriting Essentials Table of Contents Approved Paramed Vendors... 2 EZ Underwriting Program... 2 EZ Underwriting Elite, Preferred, Select Criteria... 4 Diabetes Tentative Rating Charts... 6 Uninsurable
More informationOffer clients faster and easier protection
Life insurance Offer clients faster and easier protection Accelerated Underwriting guide Faster and easier Speed up the underwriting process for both you and your clients with Principal Accelerated Underwriting
More informationUnderwriting Guidelines
Underwriting Guidelines Lincoln TermAccel Level Term LIFE SOLUTIONS Not a deposit Not FDIC-insured May go down in value Not insured by any federal government agency Not guaranteed by any bank or savings
More informationUnderwriting Guidelines
writing Guidelines Committed to Complete and Professional Risk Selections Table of Contents writing and New Business Overview... 3 Contact Information by Department... 4 Approved Facilities... 4 Connect
More informationGroup Term Life Application for 10-Year or 20-Year Level Term Rate
E Group Term Life Application for 10-Year or 20-Year Level Term Rate Please complete the entire application. The proposed insured should fill out this application. Please print clearly in dark ink and
More informationUnderwriting Requirements Guide
Voya Life Companies Fully Underwritten Life Insurance Underwriting Requirements Guide January 2018 General information... 2 Medical, inspection & APS requirements... 3 Preferred criteria... 4-5 Financial
More informationUnderwriting Guidelines
writing Guidelines Committed to Complete and Professional Risk Selections Table of Contents writing and New Business Overview... 3 Contact Information by Department... 4 Approved Facilities... 4 Connect
More informationApplicant's SSN - - Height Weight
Application to AMERICAN FAMILY LIFE ASSURANCE COMPANY OF NEW YORK (Aflac New York) 22 Corporate Woods Boulevard, Ste. 2, Albany, New York 12211 For information, call toll-free 1-800-366-3436. Aflac New
More informationBlue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers
Blue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers (Groups sized 2-150) The purpose of this document is to help you an employee requesting
More informationRoyal Advantage Term 10, 20, 30-Year Level Premium Term Life Insurance
Royal Advantage Term 10, 20, 30-Year Level Premium Term Life Insurance For certificates issued after 12/31/09 Agent Training Guide Not for public distribution Royal Advantage Term Description Level Premium
More informationING Life Underwriting
ING Life Underwriting Requirements Guide June 2010 LIFE INSURANCE For agent/registered representative use only. Not for public distribution. Your future. Made easier. ING Life Insurance Underwriting June
More informationJohn Hancock s Tickets and ExpressTrack
LIFE NEW BUSINESS A REFERENCE GUIDE TO John Hancock s Tickets and ExpressTrack FOR AGENT USE ONLY. THIS MATERIAL MAY NOT BE USED WITH THE PUBLIC. LIFE-6819 7/17 Introducing John Hancock Tickets John Hancock
More informationMEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
More informationReinstatement Application for Life Insurance California Version
American General Life Insurance Company, Houston, TX The United States Life Insurance Company in the City of New York, New York, NY (Non-NY Residents) Reinstatement Application for Life Insurance California
More informationlife underwriting condensed guide
life underwriting condensed guide For Financial Professional Use Only. Not for Use with, or Distribution to the General Public. 1 AXA Underwriting Criteria Preferred Guidelines All Applicants Term, UL/VL
More informationPersonal Declaration of Insurability
Personal Declaration of Insurability (child under age 16) In this form you and your refer to the policy owner, the parent, as the case may while we, us, our and the Company refer to Sun Life of Canada
More informationRapid Decision Senior Life. Term & Whole Life from Fidelity Life Association
Rapid Decision Senior Life Term & Whole Life from Fidelity Life Association Product, New Business and Underwriting Guide Innovation Is Our Policy www.fidelitylife.com For Producer Use Only Not for Distribution
More informationForesters Strong Foundation Simplified Issue Term Insurance
Special offer extended by popular demand Foresters Strong Foundation Simplified Issue Term Insurance Now available up to $350,000 Available through to age 55 No exams, no fluids, no APS, no routine PHIs
More informationVOLUNTARY GROUP TERM LIFE INSURANCE:
VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan
More informationlife underwriting condensed guide
life underwriting condensed guide For Financial Professional Use Only. Not for Use with, or Distribution to the General Public. 1 AXA Underwriting Criteria Preferred Guidelines All Applicants Term, UL/VL
More informationINDIVIDUAL HEALTH INSURANCE APPLICATION
INDIVIDUAL HEALTH INSURANCE APPLICATION The Insurer retains the right to contact the applicant if any question is not explained in detail or if additional information is required. New policy Additional
More informationImportant Information When Considering Portability Coverage
TERM LIFE INSURANCE ELECTION OF PORTABILITY COVERAGE Important Information When Considering Portability Coverage When your group term life insurance coverage ends, either because your employment has terminated
More informationE-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer )
E-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer ) 1. PROPOSED LIFE INSURED 2. OWNER (If not the Proposed Life Insured) Name: Male Female Last First Middle Date of Birth Age (last) Year
More informationPREFERRED UNDERWRITING CLASSIFICATIONS
term ADVISOR GUIDE PREFERRED UNDERWRITING CLASSIFICATIONS ABOUT EQUITABLE LIFE OF CANADA Equitable Life is one of Canada s largest mutual life insurance companies. For generations we ve provided policyholders
More informationMember s Signature X Date X. If you wish to apply for association group insurance, please complete the application below.
FACT MEMBERSHIP ENROLLMENT FORM MARYLAND I hereby enroll for Full Associate membership in the FEDERATION OF AMERICAN CONSUMERS AND TRAVELERS (FACT). Upon completion of this enrollment form and payment
More informationTable of Contents P R E F E R R E D U N D E R W R I T I N G GUIDE The Prudential Insurance Company of America, Newark, NJ
P R E F E R R E D U N D E R W R I T I N G GUIDE Table of Contents Introduction...2 The Underwriting Categories...2 Medical Requirements...2 Individuals Under Age 18 and Face Amounts Under $100,000...3
More informationPersonal Declaration of Insurability
Personal Declaration of Insurability (age 16 & over) In this form, you and your refer to the person insured and the policy owner, while we, us, our and the Company refer to Sun Life of Canada Philippines),
More informationq EMPLOYEE ENROLLMENT q EMPLOYEE CHANGE FORM
An independent licensee of the Blue Cross and Blue Shield Association. A subsidiary of Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association. A subsidiary
More informationlife underwriting condensed guide
life underwriting condensed guide For Financial Professional Use Only. Not for Use with, or Distribution to the General Public. 1 AXA Underwriting Criteria Preferred Guidelines All Applicants Term, UL/VL
More informationBlue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers
Blue Cross and Blue Shield of Illinois Cover Page to the Illinois Standard Health Employee Application for Small Employers (Groups sized 2-150) The purpose of this document is to help you an employee requesting
More informationReinstatement Application for Life Insurance Florida Version
American General Life Insurance Company, Houston, TX The United States Life Insurance Company in the City of New York, New York, NY (Non-NY Residents) Reinstatement Application for Life Insurance Florida
More informationProduct and Underwriting Reference Guide
Product and Underwriting Reference Guide 3-2017 UPDATE TABLE OF CONTENTS Life Product Guides Term Life... Pg. 1-4 Universal Life... Pg. 5-8 Whole Life...Pg. 9-12 Worksite Sensible Benefits...Pg. 13-16
More informationImportant Information When Considering Portability Coverage
TERM LIFE INSURANCE ELECTION OF PORTABILITY COVERAGE Important Information When Considering Portability Coverage When your group term life insurance coverage ends, either because your employment has terminated
More informationCompleted Application and Required records can be sent by mail or fax to:
KIDNEY AND KIDNEY/PANCREAS TRANSPLANT RECIPIENT APPLICATION LEGAL NAME: GENDER: Male Female (First) (MI) (Last) (Maiden) ADDRESS: DATE OF BIRTH: (Street) (Apt #) MARITAL STATUS: MARRIED (City) (State)
More informationUnderwriting requirements and preferred guidelines
Individual Life Underwriting requirements and preferred guidelines Requirements for all Symetra Life Insurance Products Face Amount Ages 0-17 Ages 18-40 Ages 41-50 Ages 51-69 Ages 70+ less than $100,000
More informationMONEYGUARD RESERVE PERSONAL HISTORY INTERVIEW
MONEYGUARD RESERVE PERSONAL HISTORY INTERVIEW INSTRUCTIONS SHOULD BE LEFT WITH THE CLIENT TO PREPARE FOR THE PERSONAL HISTORY INTERVIEW. This information DOES NOT need to be sent back to Lincoln! Dear
More informationAirport Drayage NE 112 th Ave Portland, OR 97220
Airport Drayage 6331 NE 112 th Ave Portland, OR 97220 APPLICATION FOR CUSTOMER SERVICE/OPERATIONS POSITIONS (Answer all questions Please Print Incomplete applications will not be considered) In compliance
More informationRESIDENCE ADDRESS. Council Location (City & State) MODAL PREMIUM: PART I HEALTH QUESTIONS
The Order of UNITED COMMERCIAL TRAVELERS OF AMERICA Home Office: 1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, Ohio 43215-8619 (614) 487-9680, Toll-free: (800) 848-0123, Fax: (614) 487-9675
More informationPROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE
PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122,
More informationUnderwriting requirements and preferred guidelines
Individual Life Underwriting requirements and preferred guidelines For BGA use only Requirements for all Symetra Life Insurance Products Face Amount Ages 0-17 Ages 18-40 Ages 41-50 Ages 51-69 Ages 70+
More informationCritical Illness Insurance
Choosing to plan for sudden illness Can your finances survive a serious illness? Maybe it s happened to someone you know. A sudden illness such as a heart attack or stroke can cause devastating physical
More informationELECTRONIC APPLICATION WORKSHEET
PROPOSED INSURED Last & First Name: M F Last Name at Birth: Complete Address: Date of Birth: Conserve age Tel: Work Tel: Birthplace: Since When in Canada: SIN: Legal Status: Occupation: Since: Mandatory
More informationPreliminary Underwriting Questionnaire and Authorization Information and Instructions
Preliminary Underwriting Questionnaire and Authorization Information and Instructions Thank you for taking the time to complete the following pages. It is our goal to get the best possible offer for your
More informationPRODUCT GUIDE. Term 350 Plus Life Insurance. LifeScape For Agent use only. Product availability, rates and features vary by state.
Term 350 Plus Life Insurance PRODUCT GUIDE LifeScape For Agent use only. Product availability, rates and features vary by state. 16-036-01111 (Rev. 3/25/10) Product Guide for LifeScape Term 350 Plus Life
More informationProduct Guide. Strong Foundation Your Term Level Term Life Insurance
Product Guide This guide is for information purposes only and is intended to answer your questions and provide ideas to help you sell Strong Foundation and Your Term. Check Foresters Financial producer
More informationE-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer )
E-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer ) 1. PROPOSED LIFE INSURED 2. OWNER (If not the Proposed Life Insured) Name: Male Female Last First Middle Date of Birth Age (last) Year
More informationIn-Force Change Application Arizona Version
In-Force Change Application Arizona Version American General Life Insurance Company, Houston, TX The United States Life Insurance Company in the City of New York, New York, NY (Non-NY Residents) American
More informationJUST US KIDS PEDIATRICS NEWBORN HISTORY FORM
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
More informationQUESTIONS AND ANSWERS
Webinar: What Your Life Insurance Plan Should Cover Wednesday, June 20, 2018 2:30PM (EST) QUESTIONS AND ANSWERS Bob Mullett USI Certified Financial Planner 610.537.1398 Bob.Mullett@usi.com TheAIP.com Q:
More informationNORTHSIDE PRIMARY CARE
NORTHSIDE PRIMARY CARE Dr AAZRUM I. SYED, M.D. 11820 Northfall Lane Suite 1103 ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this acknowledgment** I, have received
More informationUnderwriting Guidelines
LINCOLN FOR LIFE ADVISOR GUIDE Underwriting Guidelines Lincoln individual and survivorship products LCN2045568 The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York Not
More informationFor Producer Use Only
Foresters Financial and Foresters are trade names and trademarks of The Independent Order of Foresters (a fraternal benefit society, 789 Don Mills Road, Toronto, Canada M3C 1T9) and its subsidiaries. For
More informationIf you do not submit the Evidence of Insurability form within the 31-day period, your request for coverage will be withdrawn.
For the Employees, the Evidence of Insurability form must be completed if: You are requesting optional life insurance after your first 31 days of eligibility; or The requested amount causes your coverage
More informationWelcome to Blue Cross and Blue Shield of Illinois and
Welcome to Blue Cross and Blue Shield of Illinois and Fort Dearborn Life To enroll yourself and your eligible dependents, follow directions on the next page for help in completing the Employee Application
More informationNATIONAL SLOVAK SOCIETY OF THE UNITED STATES OF AMERICA
NATIONAL SLOVAK SOCIETY OF THE UNITED STATES OF AMERICA A Fraternal Benefit Society Application for Life Insurance Assembly/Circle #: Certificate #: 1. Proposed Insured: Male Female Height Weight Phone
More informationUnderwriting Risk Classifications
Underwriting Risk Classifications All Risk Classifications and availability by product type are listed below: (For criteria, click on a specific risk classification) Individual Life Classifications WL,
More informationPatient Registration Form
2130 South 17 th Street Suite 100 Lincoln NE 68502 Phone: 402-454-7454 Fax: 1-402-513-6547 (the 1 must be dialed when faxing to our office) Email: admin@genesispsychiatricgroup.com Patient Registration
More informationSammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
More informationTimeSaverTM. A proven solution for your impaired risk cases
TimeSaverTM A proven solution for your impaired risk cases The Crump TimeSaver TM is the most widely accepted preliminary inquiry in the industry. This powerful tool helps identify the right solution for
More informationGet the Most Out of LIFE
Item# BPD39438 (11/15) For Agent Use Only. Not for distribution to the public as sales literature. Get the Most Out of LIFE Introducing Phoenix Safe Harbor Term Life SM 160 Years of Innovation 1851: Began
More informationRelative Risk Tool Documentation - November 3,
Relative Risk Tool Documentation - November 3, 2016 2016 3 November 2016 Report of the Society of Actuaries Underwriting Criteria Team Table of Contents 1 Overview... 2 2 Limitations of the RR Tool...
More informationELA Settlement Services, LLC Data Collection Form
ELA Settlement Services, LLC Data Collection Form Complete the following forms, and mail, fax or email with any relevant documents to: ELA Settlement Services 1435 Morris Ave. P.O. Box 3137 Union, NJ 07083
More informationPlease Print in Black Ink To Be Completed by Proposed Insured Proposed Insured s Name Last First MI. DOB Sex SSN - - Month/Day/Year
SHORT-TERM DISABILITY INSURANCE (A57600 Series) Application to: American Family Life Assurance Company of Columbus (herein referred to as Aflac) Worldwide Headquarters Columbus, Georgia 31999 New Conversion
More informationICATION for VAPPLICATIONIDUAL DISABILITY INCOME. Mutual of Omaha Insurance Company Mutual of Omaha Plaza, Omaha, NE FLORIDA XXXX
Mutual of Omaha Plaza, Omaha, NE 68175 A ICATION for IN APPLICATION FOR ACCIDENTAL DEATH INSURANCE FLORIDA VAPPLICATIONIDUAL DISABILITY INCOME XXXX MAP555_FL_1212 Mutual of Omaha Plaza, Omaha, NE 68175
More informationICATION for VAPPLICATIONIDUAL DISABILITY INCOME. Mutual of Omaha Insurance Company Mutual of Omaha Plaza, Omaha, NE COLORADO XXXX
Mutual of Omaha Plaza, Omaha, NE 68175 A ICATION for IN APPLICATION FOR ACCIDENTAL DEATH INSURANCE COLORADO VAPPLICATIONIDUAL DISABILITY INCOME XXXX MAP555_CO_1212 07/01/2015 Mutual of Omaha Plaza, Omaha,
More informationThe Prudential Insurance Company of America 751 Broad Street, Newark NJ 07102
The Prudential Insurance Company of America 751 Broad Street, Newark NJ 0710 Control # 51540 Please print all answers using black ink. 1 Member Information Request for Term Life Coverage Form Return this
More information5Star Family Protection Plan Individual Term Life Insurance to Age 100 Application
5Star Family Protection Plan Individual Term Life Insurance to Age 100 Application Insurance Representative Assisted: X Section 1 - Employer Information Employer/Group Name: WTXEBC - Group Number: 01928
More informationLife-Style Final Expense Whole Life Insurance
producer guide F i n a l e x p e n s e s o l u t i o n s Life-Style Final Expense Whole Life Insurance Simplified Simplified Issue Whole Life Insurance - Level Benefit policy form series ICC14 NCL-60B
More informationApplication Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage NEBRASKA
Mutual of Omaha Insurance Company P.O. Box 3608 Omaha, Nebraska 68103-3608 Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage NEBRASKA THIS APPLICATION MUST BE USED TO
More informationHIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ TEL:
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ 08904 TEL: 732-393-1331 www.hpfamilypractice.com PATIENT INFORMATION: Patient s Name (Last) (First) (Middle)
More information