Welcome To Pacific Retirement Planning

Policy amount requested: $

Term/plan requested: 10 year level premium term 15 year level premium term 20 year level premium term 30 year level premium term Permanent life insurance without cash value Permanent life insurance with cash value Other

if "Other" (please specify):

First Name / MI / Last Name:

State of Residence: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Date of Birth: January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Height: 3 4 5 6 7 ft. 1 2 3 4 5 6 7 8 9 10 11 in.

Weight: lbs.

Sex:

Male   Female

Tobacco or nicotine usage:

Yes   No

Are you currently taking any prescription medications:

Yes   No

Have you, or your natural parents or siblings, had an occurrence of cardiovascular disease or cancer before the age of 60?:

Yes   No

Do you or do you expect to participate in motor vehicle racing, scuba, or sky diving?:

Yes   No

Do you plan to travel outside the United States or Canada for business or pleasure within the next 24 months?

Yes   No

Telephone:

Home  

Work       (Please provide at least one.)

Cell    

Best time to call: No Preference Morning Midday Afternoon Evening

Email:

Additional comments or information which you feel may affect the underwriting of your policy:

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