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BULLET LIFE INSURANCE - Get a Quote!

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Fields marked with * are required

Producer:

* Agent Name:

   Address:

   City:

   State:

  Zip:

* Email Address:

* Phone #:

* Fax #:

* Return Method:

Client:

Insured #1

* Name:

* Birth date:

* Gender:

Male Female

* Health Class:

Preferred Standard

  Tobacco Use:

Pipe Cigar Chewing

  Cigarettes:

(If quit, last used: )

  Medical Problems:

  Medications & Dosage:

Insured #2

  Name:

  Birth date:

  Gender:

Male Female

  Health Class:

Preferred Standard

  Tobacco Use:

Pipe Cigar Chewing

  Cigarettes:

(If quit, last used: )

  Medical Problems:

  Medications & Dosage:

Illustration:

* Primary Objective: Death Benefit Cash Accumulation Guarantees Low Premium

* Face Amount(s):

  Specified Carrier:

* Product Type: Universal Life Whole Life Whole Life Blend % Term Variable Survivorship

                           Other


* Payment Plan:
Level  -Pay  -Pay  To Age   1035 Rollover:

                           Other Dump-In:


* Cash Value Target:
Endow Alternative Amount: at Maturity or Age


  Interest/Div. Rate:
Current Other: %


* Payment Mode:


* State of Issue:

Riders:

Term Rider - Insured   Amount:  To Age:   Term Rider - Other

Name:

Birth date:

Amount:

To Age:

Waiver of Premium Child Insurance     Rider:   ADB:

Other:

Special Instructions:

800 Bering, Suite 105 Houston, TX 77057
(713) 507-1000 (800) 477-3548 Fax:(713) 507-1090 elite@elitemktg.net

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