Form Tfm 220 0113 - New Business Cover Sheet
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1Transamerica Life Insurance Company
New Business Cover Sheet
Fax to: 800.535.1325
Date: _____________________
Number of pages including this cover sheet: _____________________________
Agent #: ___________________________________
Agent name: ________________________________________
Agent phone #: ______________________________
Agent fax #: ________________________________________
Preferred e-mail address for pending policy updates: _____________________________________________________
Proposed insured’s name: __________________________________________________________________________
Best time of day/evening to call them: ____________
Special language needs? ______________________________
If this is a companion policy, write companion name: ___________________________________________________
Forms Checklist
Please Write the Name of the Product Being Applied for Here ________________________________________________
For All Products
Primary Additional
Insured
Insured
Office ID# 13980
Application
HIPAA Authorization Form
For illustration software go to
,
(Required for Long Term Care Rider on TransACE)
Software Downloads, TransWare
®
Terminal Illness Form, if applicable
When completing the APA40 app be sure
Initial Premium or Pre-authorization Form
to indicate:
HIV Consent Form, if applicable
Underwriting Class being applied for
Replacement Form, if applicable
exactly as it appears on the illustration.
Form must be dated same as, or earlier than the application
Kind Code - also found on the quote
Illustration, if applicable
page of the illustration.
All pages are required in NAIC states for Universal Life
TransACE
Only - LTC Rider Supplemental App
®
RAP (Required Annual Premium) -
found in the upper left corner of the
IUL Only - Index UL Policy Certification,
Producer Quote page of the illustration.
Statement of Understanding AND
IUL Supplemental App
Company Scheduled to do Paramed
Transfer or 1035 Exchange Form, if applicable
APPS
ExamOne
Other
Mail original 1035 form, within 5 working days of the fax
EMSI
Portamedic
Health Questionnaire (list type), if applicable
Medical Requirements, if applicable
Lab Slip/Bar Code #:
__________
Date Taken:
_____
Order all necessary Medical Requirements, indicate
orders on Agent’s Report
Is this an Internal Replacement/or Conversion?
___________________________________________________________________
If yes, Policy number
Other (please explain)
_______________________________________________________________________________
Special Instructions:
___________________________________________________________________________________________________
• Submit initial application and forms ONLY ONCE, either via fax, , or mail.
To speed
Tips!
.
• If you choose to fax your application, please retain your original copy of this fax. We reserve the right to request
processing..
a re-fax of the original if we are unable to read the fax. Do NOT mail the original application and forms you have
previously faxed, unless requested to do so.
• Print legibly, in English, and use black ink.
• Do NOT use white-out.
• Make sure all necessary supplemental forms are included.
Life insurance products issued by Transamerica Life Insurance Company, Cedar Rapids, IA. 52499
TFM 220 0113
For producer use only. Not for distribution to the public.
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Parent category: Business