Agent Name

Advisor Email Address

Client Name

Client Date of Birth

Client City and State

Product Type Product TypeFixed Indexed AnnuitiesFixed AnnuityWhole LifeUniversal LifeTerm LifeLong Term CarePremium Finance

Surrender Year Surrender YearN/A3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years

Investment Premium

Client Goals and Needs

Marital Status Marital StatusSingleMarried

Client Health Client HealthSmokingNon-Smoking

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