Lanny D. Levin Agency; http://www.levinagency.com - Request Survivor Life Proposal

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Profile of Insured 1
Proposed Insured:
State:
Age or Date of Birth:
Gender:	Male Female
Tobacco User:
Underwriting Class:	Preferred Plus (Best) Preferred (standard non-cigarette smoker) Standard (any cigarette smoker)
Comments:

Profile of Insured 2
Proposed Insured:
State:
Age or Date of Birth:
Gender:	Male Female
Tobacco User:
Underwriting Class:	Preferred Plus (Best) Preferred (standard non-cigarette smoker) Standard (any cigarette smoker)
Comments:

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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.

1751 lake cook road, suite 350, deerfield, illinois 60015