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Client:

Insured #1

Male Female

Preferred Standard --Select Health Class-- Preferred Best Preferred Non-Smoker Preferred Smoker Standard Non-Smoker Standard Smoker Substandard

Pipe Cigar Chewing

(If quit, last used: )

  Name:

  Birth date:

  Gender:

Male Female

  Health Class:

Preferred Standard --Select Health Class-- Preferred Best Preferred Non-Smoker Preferred Smoker Standard Non-Smoker Standard Smoker Substandard

  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: Select one Annual Semi-Annual Quarterly Monthy

* 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: