Case Information Agent Name * Agent Phone * Case Option * Express BASICExpress PLUS Express BASIC: PLEASE COMPLETE ALL SECTIONS OF THIS FORM AS ACCURATELY AS POSSIBLE. You have discussed the need for life insurance with the client and/or policy owner, and have run illustrations for the client. Once we receive this ticket, we will contact the client and complete the full life application, secure all signatures, and order & follow-up on all requirements. Once underwriting is complete and the offer is received, we will send the info back to the AGENT, and mail the policy to the AGENT for placement. You are agreeing to split the Agent-Level Compensation 90% Agent/Agency, 10% MWLB Express. Express PLUS: PLEASE COMPLETE ONLY SECTION 1 OF THIS FORM AS ACCURATELY AS POSSIBLE. Your client has requested life insurance from you, but you don't have the resources to discuss the case with him/her. Once we receive this ticket, we will contact the client and complete a quick needs anaylsis, run life illustrations, complete the full life application over the phone, secure all signatures, and order & follow-up on all requirements. Once underwriting is complete and the offer is received, we will present to the CLIENT, and mail the policy to the CLIENT directly for placement. You are agreeing to split the Agent-Level Compensation 75% Agent/Agency, 25% MWLB Express. Section 1 -- Proposed Insured Information First Name * Middle Initial Last Name * Street Address * City * State * Zip Code * Sex * —Please choose an option—MaleFemale Home Phone * Cell Phone Work Phone Client's EMail Address U.S. Citizen YesNo Birth Date * Last 4 of SSN Tobacco Usage —Please choose an option—SMOKES CIGARETTESNEVER SMOKEDQUIT MORE THAN 1 YR AGOQUIT MORE THAN 3 YRS AGOUSES A NON-CIGARETTE NICOTINE (SUCH AS NICORETTE, CIGARS, PIPES, ETC..) Employer Approximate Annual Earned Income Section 2 -- Proposed Life Insurance Carrier Product Face Amount Riders Discussed Quoted Underwriting Class —Please choose an option—SUPER PREFERRED NON-SMOKERPREFERRED NON-SMOKERSTANDARD PLUS NON-SMOKERSTANDARD NON-SMOKERPREFERRED SMOKERSTANDARD SMOKERRATED CASE Quoted Annual Premium Section 3 -- Other Information Policy Owner Beneficiary Does the client have other coverage? —Please choose an option—YesNo Is this policy replacing coverage? —Please choose an option—YesNoIt Depends Does the client take part in any hazardous sports activities? —Please choose an option—YesNo Does the client a private aviator? —Please choose an option—YesNo Does the client take any medication on a regular basis? —Please choose an option—Yes (Explain More Below)No Does the client have any surgical procedures that have been discussed but not completed? —Please choose an option—YesNo We will do our best to contact your client at the requested date and time. If you have discussed a date/time that works for your client, please enter it here: Upload Docs to MWLB Express Proposed Tele-Interview Date Proposed Tele-Interview Time Thank you for your business!
