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PLEASE FILL OUT FORM BELOW State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa Birthday: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 Sex: Male Female Smoker?: Yes No Your Health: Regular  Regular Plus  Preferred  Preferred Plus  Initial Term: 20 Year     ** Read Note Below 30 Year     ** Read Note Below 5 Year - Guaranteed Only 10 Year - Guaranteed Only 15 Year - Guaranteed Only 20 Year - Guaranteed Only 10 versus 20 Year Term 10 versus 15 versus 20 25 Year - Guaranteed Only 30 Year - Guaranteed Only 20 versus 30 10 versus 20 versus 30 All Guaranteed Above Age to 100 Level Guaranteed 15 Year Return of Premium 20 Year Return of Premium 30 Year Return of Premium Shown as: Annual Monthly Quarterly Semi-Annual Amount: $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $600,000 $700,000 $750,000 $800,000 $900,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,500,000 $3,000,000 $5,000,000 First Name: Last Name: Phone: Email: