Get Pre-Approved For Retirement Insurance Book A Call Or Fill A Form Meet Mak and Ann Schedule a time to speak with Mak or Ann Annuities Client Intake FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Agent do you understand these policies are fully underwritten and may take 45-60+ days for approval and will require Paramedical Exams etc. *YesNoAgent Full Name *Agent Phone Number *Agent Email *Agent Resident State *Agent Lafayette Contracted? *YesNoAgent First Time Submitting Business? (with Lafayette) *YesNoAre you submitting business in LA, MT, OK, PA, TX? *Yes - State license must be active before application sign dateNoSingle Line TextAgent Writing # (if not enter N/A) *Lafayette Life Writing NumberClient Full Name *Client Phone *Client Gender *MaleFemaleClient Email *Client Date of Birth Or Age *Client Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCheck all that apply? *MarriedSingleNo Children1-2 Children3+ ChildrenPurpose of the Policy? *Do you currently have life insurance?NoneTermIULWhole LifePurpose of Infinite Banking Policy *Paying of Credit Card DebtPurchasing Item (car, realestate, equipment)Saving Alternative (emergency fund)College FundingOtherDo you use nicotine? *NoCigaretteCigarNicotineDip/Chewing TobaccoVapingMarijuanaOtherMonthly Premium / Investment *$250-$500$500-$1000$1000+Does client have cash savings/checking for initial lump sum? (excluding 401K's, 403b, 457s, TSP) *None500-10,00010,000-25,00025,000+Does client own a home?YesNoRemaining Mortgage Amount (estimated)? *Client Credit Card Debt? 0-$5000$5000-$10000$10000+Own Or Lease A Car? *OwnLeaseContribute To 401k, 403b, 457, Etc: *None0-$250$250-$500$500+After expenses how much is contributed to savings/emergency/money market? *$0-$250$250-$500$500+Client Medical Info (Health qualifications): *Cancer (within 5yrs)HIV/AidsHeart ConditionsStrokeCOPDDiabetesCongestive Heart FailureAnxietyPTSDDepressionDisability (VA)Disability (FEDERAL)Thyroid IssueTumorsColitis / Chrons DiseaseSubmit
