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New Business Submission Form
Office Location
Choose an option
Date Submitted to Carrier
*
required
Company
Product Name
This policy is...
New Business
Re-Write of Policy Submitted in Last 6 Months
Correction of Previous Submission
Product Type (Note: Do Not Submit Part D Plans)
*
Medicare Supplement
Medicare Advantage
Major Medical
Incidental
Final Expense / SIWL
Universal / Term / Whole Life
Single Premium Life
LTC / ASSI
Annuity
Applicant's LEGAL First Name
Applicant's LEGAL Last Name
Date of Birth
*
required
Street Address
City
State
Zip Code
Phone Number
Gender
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IF MEDICARE, Effective Date
Type of Medicare
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IF LIFE, Death Benefit Amount
IF ANNUITY, Tax Status
Choose an option
Source of Sale (Note: Use 'Existing Client' as a last resort! Where did the Client orginate?)
*
Affinity Lead / Affinity Marketing Effort
Agent Lead / 3-Ft Rule
Door Knock
Existing Client (Last resort. Please select source where client originated.)
Internet Lead / Online Marketing
Life Lead
Mail Lead / Responder
Orphan
Prospect / Cold Call
Referral
Seminar - Health/Medicare
Seminar - Financial
Telemarketer / Link Serve
Warm Mrkt / Family / Friend / Self
Other
Application Type
*
Paper App
Phone App
E-App Direct w/Carrier
E-App w/iPipeline
E-App w/MAX Firelight
E-App w/MedicareCenter
Agent Name on Application (0%) if different from paid agent(s)
IF MEDICARE, Writing agent name on actual application
Premium Mode
*
Monthly
Quarterly
Semi-Annually
Annually
One-Time
Annual Premium
Primary Agent (This Agent has client in their MAX.)
Share (%)
First Year Commission
Splitting Agent
Share (%)
First Year Commission
Third Agent
Share (%)
First Year Commission
Did you review SAGE and commit to enroll on delivery?
*
Yes!
No
Tuition Reward Points you expect to award to client
SUBMIT
Thanks for submitting!
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