Case Design Request Form
Client Information
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Name of spouse or significant other
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
State of Residence
(Required)
Health Classification
Health Class
(Required)
Preferred
Standard
Tobacco Use
(Required)
Yes
No
Policy Details
Specify Premium amount, Frequency, and Payment Term
(Required)
Example: "$12,000/yr for 10 years" or "$1,000 monthly for lifetime pay" or "$150,000 single pay"
And/or Specify Death Benefit
Product Preference
(Required)
WL (Whole Life)
UL (Universal Life)
IUL (Indexed Universal Life)
LTC (Long-Term-Care)
Term 10
Term 15
Term 20
Term 25
Term 30
Other
Additional Info
Advisor Name
(Required)
Phone #
(Required)
Email
(Required)
Desired Date Needed
(Required)
MM slash DD slash YYYY
Notes