AIS Illustration Request Form
Advisor Information
Advisor Name
Firm Name
Today's Date
Email Address
Phone Number
Client Information
Client Name
DOB or Age
Gender
Male
Female
Tobacco Use
Yes
No
State
Purpose of Insurance (ie. Protection, accumulation)
Product Type
Term
Perm
If
Perm
(UL, IUL, VUL, WL) or If
Term
# of years (up to 3 choices)
Amount
Face
Premium
Face Amount or Monthly Premium ($)
Any know Medical Issues, or NA
Expected Underwriting Rating (Standard, Preferred, Preferred Best)
Face Option (Guaranteed to age/year: or Option B: or ROP)
If Option B: Changing to Level at Age/Year
Estimated 1035 Exchange Amount
Years to Pay
Premium Mode
Preferred Carriers of NA
Riders Requested
Any other comments, or Let us know if you would like a Call
Are you Licensed in the State you want to apply?
Yes
No (If no, let Insurance team know, and you will need to be registered BEFORE appliation)
Contact Information