Please print, fill and fax to: (585) 424-3647Phone: 535-424-4330 gina@promarkny,comLife Insurance Proposal Request

Agent Name: ____________________________________ Phone Number: ___________

Client Name: ____________________________________ Date of Birth: _____________

Spouse Name: ___________________________________ Date of Birth: _____________

Product Requested:

Term InsurancePurpose of Insurance:

Duration:

Face Value: Guaranteed Face Amount/Premium

Yes No

Alternate Money: Riders:Waiver of Premium

YesNoAD&D

Medical History: Circle those that apply

Client Tobacco Stroke Diabetes Cancer Heart DiseaseSpouse Tobacco Stroke Diabetes Cancer Heart Disease

Additional Medical History and Medications (Please indicate Client (c) or Spouse (s)):

Both Applying?

Permanent Insurance Universal LifePurpose of Insurance:

Duration:

Face Value: Guaranteed Face Amount/Premium Yes No

Alternate Money: Riders:Waiver of Premium

YesNoAD&D

Immediate Family History—Death before age 60? Cause of Death: