Survivorship Life Illustration Request Form - CPS Advantage

Financial Advisor:

First Last

Phone Number:

Email:

APPLICANT 1

Name or Initials

DOB or Age

Gender

Female

Male

Underwriting Class: Preferred? Standard? If Rated, how?

Tobacco use during past 12 months, including type & frequency:

Any Medical History / Prescriptions / Medical Devices / Family History / MVR / Private Aviation / Hobbies / Travel / Bankruptcy / Criminal Record?

APPLICANT 2

Name or Initials

DOB or Age

Gender

Female

Male

Underwriting Class: Preferred? Standard? If Rated, how?

Tobacco use during past 12 months, including type & frequency:

Any Medical History / Prescriptions / Medical Devices / Family History / MVR / Private Aviation / Hobbies / Travel / Bankruptcy / Criminal Record?

CASE DESIGN

Death Benefit(s)

Premium Frequency

1035 $

State of Residence or Trust

Anything else we need to know about the applicants or to optimize case design? Short pays? Pay premiums for how many years?

CA Corp. Insurance License: 0E02059

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Phone: (562) 431-4000

Email: requests@cpsadvantage.com

Mail & Overnight Address

CPS Advantage
3020 Old Ranch Parkway #300
Seal Beach, CA 90740