Ken Leshaw Agency

Permanent Life Quote Request Form

Client
Insured #1
Name:
Birthdate:
Gender:	Male Female
Health Class:	Preferred Standard
Tobacco Use:	Pipe Cigar Chewing
Cigarettes:	(If quit, last used: )
Medical Problems:
Medications & Dosage:
Insured #2
Name:
Birthdate:
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:

Term: ART 5 10 15 20 30
Other:

Super-Preferred?:	If so, HT: WT:
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:
Annual Semi-Annual Quarterly Monthly
State of Issue:
State in which insurance is to be issued -
Riders
Term Rider - Insured Amount: To Age:
Term Rider - Other
Name:
Birthdate:
Amount:
To Age:
Waiver of Premium
Child Insurance Rider:
ADB:
Other:
Mail, Phone and Fax (If other than Agent Information):


Special Instructions:

Supplies:
Appointment Forms Application Packs Product Information
Your request cannot be honored unless this form is completed.