EN
ES
New Business Transmittal
Agent form
Do not fill:
Agent information
Agent name
*
Agent number / Writing #
*
Email
*
Phone
Submission date
Type of new business
Life
Life insurance
Annuity
Annuity contract
RBM
Reverse Banking Method
Alternative
Investment
Client / Proposed insured
Full name
*
Date of birth
Phone
Email
State of residence
Life details
Carrier name
*
Product type
*
Select…
Term
ROP (Return of Premium)
IUL (Index Universal Life)
FE (Final Expenses)
WL (Whole Life)
UL (Universal Life)
Face amount
Premium
Payment mode
Select…
Monthly
Quarterly
Semi-Annual
Annual
Application / policy #
Annuity details
Carrier name
*
Amount to invest or rollover
*
Time
*
RBM (Reverse Banking Method) details
Lump Sum Value
*
Face Amount
*
Alternative Investment details
Amount to invest
*
Project name
*
Time
*
Additional information
Is this a replacement?
Yes
No
Split case?
Yes
No
Notes or comments
I confirm the information is correct and the application was completed according to carrier rules.
*
Submit new business
Business submitted!
Your submission was received.
Copy summary
Print / PDF
New submission
