Illustration Request
(NO TERM REQUESTS PLEASE)
  Producer:
Agent Name:
Company:
State:
Email:
Phone #:
Fax #:
   Client:
Insured #1 :
Name:
Birthdate:
/ /
Gender:
 Male Female
Rating:
 Preferred Standard
Substandard (Have underwriter contact me)
Tobacco:
 Cigarettes Pipe Cigar Chew
None
If quit, when: Month Year
Insured #2 :
Name:
Birthdate:
/ /
Gender:
 Male Female
Rating:
 Preferred Standard
Substandard (Have underwriter contact me)
Tobacco:
 Cigarettes Pipe Cigar Chew
None
If quit, when: Month Year
   Illustration:
Primary Objective:
 Death Benefit Cash Accumulation
Guarantees Low Premium
Face Amount(s):

Specified Carrier (Optional):

Product Type:
 Individual Survivor 1st to die
Interest Sensitive:
 Universal
Variable - Important! You must complete the following if you choose Variable:

Broker/Dealer Name:

CRD#:

Traditional:
 Whole Life
Whole Life Blend: 50-50
Whole Life Blend: 75-25
Term:
 ART 5 yr. 10 yr.
15 yr. 20 yr. 30 yr.
Other:

Payment Plan:
 Level or
Short Pay - Years to Pay Premium:
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:
Special Instructions:

Supplies:
 Appointment Forms
Application Packs
Product Information
An illustration cannot be provided unless this form is completely filled out.
Questions? Call (800) 225-9844
If your client has a history of health-related impairments, click on:



Variable products offered through Interlink Securities Corporation
( in California DBA Interlink Securities Insurance Services), Member NASD/SIPC