To run your own quote through WinFlex Web click here Permanent Life Quote Broker InformationAgent Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Email* Business Phone*Cell PhoneFaxClient InformationApplicant's Date of Birth Applicant's Name First Last Applicant's Sex Male Female Tobacco History:NoneCigaretteCigarChewCurrent or date of last use:Quote a preferred class on the applicant? Yes No Client 2 InformationSecond Applicant's Date of Birth Second Applicant's Name First Last Second Applicant's Sex First Choice Second Choice Tobacco History:NoneCigaretteCigarChewCurrent or date of last use:Quote a preferred class on the second applicant? Yes No Quote InformationState of quotePrimary objective Death Benefit Cash Accumulation Retirement Income Other objectives / needs Key Man Family Protection Buy Sell Loan / Debt Repayment Other If "Other' please explain:Face amounts(s)Specified carrierProduct InformationPayment Mode Single Premium Full Pay Short Pay Plan Type Universal Life Index UL Survivorship UL Variable UL Permanent - Desired Interest RatePermanent - Alternate Interest RateShort Pay OptionsSuspend Pay - At ageSuspend Pay - In Specific YearPayment ModeAnnualSemi-AnnualQuarterlyMonthyAdditional Premiums1035 ExchangeLump SumDeath Benefit Option Level Increasing RidersRiders - Child RiderSpecify Gender, Age, & AmountRiders - Waiver of Premium Yes No Riders - Accidental Death Benefit Yes No Specify Amount:Case InformationAre you in competition for this case? Yes No If yes, please specify:Additional comments or health concerns?
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