Agent Information

          Name   

          Title  

          Business Name  

          check here to use address of record  

          Mailing Address  

          Address (cont.)  

          City  

          State  

          Zip Code  

          Work Phone   

          Fax Number  

          E-mail  

          check here to update your address of record  

Client Information

          Name #1   

          Date of Birth    (mm/dd/yyyy)

          Sex   Female Male

          Tobacco User   No Yes

          If Yes, Describe Usage  

          General Health / Existing Conditions  

          
          Name #2  

          Date of Birth   (mm/dd/yyyy)

          Sex   Male Female

          Tobacco User   No Yes

          If Yes, Describe Usage  

          General Health / Existing Conditions  

          State & Zip Code of Residency   

          Income During Retirement   $

          Approximate Assets   $

Policy Information

             Non-Partnership                  Partnership   New York Connecticut Other

                                                                               if other indicate what state  

          Elimination Period   0 Days 20 Days 30 Days 45 Days 60 Days 90 Days 100 Days 180 Days 365 Days

          Policy Max Benefit   2 Years 3 Years 5 Years 7 Years Unlimited

          Daily Benefit Limit ($70 - $350)

                    Nursing Home   $

                    Home Health Care   50% 60% 75% 80% 100%

          Inflation Option   5% Compound 5% Simple CPI None

          Benefit Option   Daily Monthly Cash

          Limited Pay Option   10 Pay Reduced Pay at Age 65 Paid Up at Age 65

          Additional Riders

   Non-Forfeiture             Shared Benefits             Restoration of Benefits

   Dual Waiver of Premium             Survivorship

NOTE - elimination periods, benefit periods, and daily benefit options may vary by company.  NOT all companies have all riders available.

This Illustration Is Needed By:      (mm/dd/yyyy)

I Would Like My Request Sent By:

                  E-mail        Fax       Mail