Suitability Client Suitability Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Who Referred You? Please Enter your MGA, BGA, GA, RVP *FIRST INSURED *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *First Insured Age *Underwriting ClassificationSelect Rate ClassElitePreferredSelect StandardStandardPreferred TobaccoStandard TobaccoTable RatedEmail Address *Gender *SelectMaleFemaleSecond Insured *FirstLastSecond Insured AgeUnderwriting Classification *Select Rate ClassElitePreferredSelect StandardStandardPreferred TobaccoStandard TobaccoTable RatesSecond GenderSelect Insured GenderMaleFemaleProposed Insured Networth (Excluding Primary Residence)Current Life Insurance In-forcePurpose of Insurance (Estate, Income)SelectFamily NeedsEstate PlanningRetirement IncomeBuy Sell AgreementNet Death Benefit RequiredDesired Out of Pocket PaymentBorrowing Entity (Select)SelectIndividualCorporationCompanyIrrevocable TrustRevocable TrustSpecial Purpose Vehicle (other)Optin for EmailsYes, I would Like to receive emails on Premium Finance Strategies.Current Annualized IncomeCredit Score (if known)Preferred CarrierSelect CarrierLSWAIGAllianzAmeritasAXAJohn HancockLincolnMass MutualNew York LifeNationwideSecurianSymetraOtherDesired Income StreamMaximum Collateral (not to exceed)Loan Payoff Method, Exit StrategySelectLoan Paid with Policy FundsLoan Paid with Outsider FundsSend to Case Design Team
