Test form – ULTRA Estate Planning

Trail Application

Step 1 of 7

PERSONAL INFORMATION
Full Name*
First Name Last Name
Address*
Address Line 1 Address Line 2
Phone Number*
Date of Birth*
MM slash DD slash YYYY
Male/Female*
- Male
- Female
Social Security Number*
Driver's License/State*
Occupation*
Do you Smoke?*
- Yes, what and how much?
- No, never smoked
- No, but quit
Name, address and phone number of personal or attending physician*
Medications you currently take*

FINANCIAL INFORMATION
Income Information
Salary*
Company pension*
Social Security*
Investment income*
IRA distribution*
Other*
Total income*
Living expenses*
Taxes (State & Federal)*
Gifts to family*
Federal income tax bracket*
State income tax bracket*
Financial Information (Attach a financial statement if available)
Assets
Primary Home
Market Value*
Cost Basis*
Growth Assumption*
Secondary Home
Market Value*
Cost Basis*
Growth Assumption*
Real Estate
Market Value*
Cost Basis*
Growth Assumption*
Business
Market Value*
Cost Basis*
Growth Assumption*
Stocks
Market Value*
Cost Basis*
Growth Assumption*
Mutual Funds
Market Value*
Cost Basis*
Growth Assumption*
Annuities
Market Value*
Cost Basis*
Growth Assumption*
Tax Free Bonds
Market Value*
Cost Basis*
Growth Assumption*
Money Markets
Market Value*
Cost Basis*
Growth Assumption*
Retirement Plans
Market Value*
Cost Basis*
Growth Assumption*
Notes Receivable
Market Value*
Cost Basis*
Growth Assumption*
Other
Market Value*
Cost Basis*
Growth Assumption*
Total Assets*
LessLiabilities*
Net Worth*
Plus Personally Owned Life Ins.*
Taxable Estate*
Do you anticipate any inheritances?*
- Yes
- No
Estimated amount*

Agent Information
Agent Name*
First Name Last Name
Agent Contact*
Address*
Street Address
Phone Number*
Fax Number*
E-mail Address*
Social Security Number*
Notes and Special Consideration:*
Case Manager*

This authorization complies with the HIPAA Privacy Rule*
NOTICE TO PROPOSED INSURED*
NOTICE OF INFORMATION PRACTICES*

COMPANIES

Accordia Life and Annuity, A Global Atlantic Company	Minnesota Life
American Equity	Mutual of Omaha
American General	National Life Insurance Company
American General Life & Accident	National Western Life
American National	Nationwide Life
Americo Financial Life and Annuity Insurance Company	New York Life
Ameritas Life	North American Company
Assurity Life	Pan-American Assurance Company International, Inc.
Athene	Penn Mutual Life Insurance Company
AXA Financial	Principal Life Ins Company
Banner Life	Principal National Life Insurance Company
Brighthouse Life Insurance Company	Protective Life
Brighthouse Life Insurance Company of NY	Protective Life & Annuity NY
Centrian Life	Prudential
Companion Life	Reliastar Life Insurance Company
Examination Mgmt Services, Inc.	Reliastar Life Ins Company of NY
Express Imaging Services, Inc.	SBLI
Fidelity & Guarantee Life Insurance Company	Securian Life
Fidelity & Guarantee Life Insurance Company of NY	Security Life of Denver
First Symetra National Life Insurance Company of NY	Security Mutual Life of NY
Foresters	Standard Insurance Company
Freundt & Assoc Insurance Services, Inc.	State Life/One America
General Re Life Corp	Symetra
Great American Life	The Standard Life Ins Company of NY
Guardian Life	Transamerica Life Insurance Company
John Hancock	Transamerica Financial Life Insurance
Life of the Southwest	Union Central
Life Secure	United of Omaha
Lincoln National Life Insurance Company	United States Life Insurance Company in the City of NY
Lloyds of London	VOYA Insurance & Annuity Company
Mass Mutual	William Penn
MetLife Insurance Company USA	Zurich American Life Insurance Company
Metropolitan Life Insurance Company	Zurich American Life Insurance Company of NY

If you would like to receive a more detailed explanation of a company’s information practices or if you would like to revoke this authorization, please send your request in writing to:

The Producers Group, affiliate of Freundt and Associates Insurance Services, Inc.

Attn: Privacy Official.

Signed at*
Date*
MM slash DD slash YYYY
X (Signature of Proposed Insured)*

X (Signature of Proposed Insured)
Name Proposed Insured (please print)*

Name Proposed Insured (please print)

Trail Application

Step 1 of 7

PERSONAL INFORMATION

HEALTH QUESTIONNAIRE

FINANCIAL INFORMATION

Financial Information (Attach a financial statement if available)

Requested Plan of Insurance

Insurance currently pending or applied for with all carriers:

Concept Information

Agent Information

COMPANIES