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REQUEST SINGLE LIFE PROPOSAL
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Insured Information
Proposed Insured:
State:
Age or Date of Birth:
Gender:
Male
Female
Tobacco User:
No tobacco of any kind for 24 months or more
No tobacco of any kind for 48 months
No cigarettes within 12 months, no other tobacco
No cigarettes within 12 months, uses cigar or pipe or chew only
Abstained from all tobacco less than 2 years
Has smoked a cigarette within 12 months
Underwriting Class:
Preferred Plus NT
(no tobacco for 48 months)
(Minimum face amount $250,000)
Preferred NT
(no tobacco for 24 months)
(Minimum face amount $100,000)
Non-Smoker
(no cigarettes for 12 months)
Standard
(Cigarette smoker within the past 12 months)
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Please note: you will have the opportunity to "clone" this request to obtain additional variations for this insured or obtain similar proposals for additional insureds.
voice 847-597-2400 fax 847-597-2401
www.levinagency.com
1751 lake cook road, suite 350, deerfield, illinois 60015
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