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?

Securities Offered Through Variable Life Brokerage Distributors
a division of ING Financial Partners, Inc.
Member SIPC
Diversified Underwriters Services Inc., is not a subsidiary of nor controlled by VLBD/ING Financial Partner, Inc.

© 2005 Diversified Underwriters Services, Inc. Portions ©2005 BISG, Inc.