Protective Life Quick Application
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1Protective Life Quick Application
Name (first, middle, last):
Gender:
Female
Male
Birthdate:
Weight:
Height:
State of birth:
Social security #:
Home address:
Secondary phone number:
Primary phone number:
Drivers license state:
Drivers license number:
Net worth:
Annual income:
Email address:
Have you ever used any form of tobacco or nicotine based products?
No
Yes
If yes, when did you last use tobacco or nicotine based products? (month/year)
Product type:
Term
Indexed UL
Universal Life
Duration (for term only):
Age 105
10 year
15 year
20 year
25 year
30 year
Age 121
Amount of Insurance:
$1,000,000
$1,500,000
$250,000
$500,000
Other:
Billing frequency:
Monthly(EFT)
Quarterly
Semi-Annual
Annual
What is the purpose of this insurance?
Key man
Buy/sell
Family protection
Other:
Income replacement
Include Income Provide Option
? (If yes, please answer questions below)
No
Yes
or
Death benefit payment frequency:
Payment period (for UL/indexed UL only):
Annual
Monthly
Pay to year
Pay to age
Death benefit payment:
Base policy lapse protection duration: age
Number of benefit years:
Indexed (for index UL only): _________%, Fixed: _________%
Death benefit payment date:
Include Riders?
(If yes, please answer questions below)
Yes
No
Disability benefit rider:
Monthly specified amount:
No
Yes
Yes
Childrens insurance benefits:
No
Coverage per child:
Accidental death benefit:
Yes
Coverage amount:
No
Do you have existing life insurance?
(If yes, please provide details below)
Yes
No
Company:
Company:
Policy # (if known):
Policy # (if known):
Face amount:
Face amount:
Year issued:
Year issued:
Beneficiaries:
Beneficiaries:
Will this be replaced?
Will this be replaced?
No
Yes
No
Yes
Have you ever had a request for live insurance declined, postponed, or offered other than as applied for?
No
Yes
(If yes, please provide details):
Do you have an application pending in another company?
No
Yes
(If yes, please provide details):
Is there an intention that any party other than the owner will obtain any right, title, or interest in any policy issued on the life
of the proposed insured as a result of this application?
Yes
No
(If yes, please provide details):
For any policy to be issued as a result of this application, will any portion of the initial or future premiums be borrowed,
loaned or otherwise financed?
No
Yes
Would you like to have your policy electronically delivered when it is issued?
No
Yes
Policy Owner (if other than proposed insured)
a. Full legal name
b. DOB
c. SSN
d. Relationship
e. Addresss
Primary Beneficiary
Beneficiary #1
Beneficiary #2
Beneficiary #3
a. Full legal name
c. Relationship
d. Percentage of share
Contingent Beneficiary
Contingent #1
Contingent #2
Contingent #3
(optional)
a. Full legal name
c. Relationship
d. Percentage of share
Agent Information
Primary Agent
Secondary Agent (if split case)
a. Name
b. Agent ID
c. Split % (if applicable)
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