Notice To Owner Regarding Replacement Of Life Insurance Page 6
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7Comparative Information Form for
Proposed Insurance
Exhibit B
(Complete if Owner’s initials are present in “YES” box on Exhibit A.)
MUST BE PRESENTED TO, SIGNED AND DATED BY THE OWNER AND PRODUCER AT THE TIME OF APPLICATION
Proposed Insurer: ________________________________________________________________________________________________
Insurer’s Address: ________________________________________________________________________________________________
Replacing Agent’s Name: __________________________________________________________ _________________________________
O O W W N N E E R R I I N N F F O O R R M M A A T T I I O O N N : :
P P O O L L I I C C Y Y I I N N F F O O R R M M A A T T I I O O N N : :
Name _______________________________________________
Policy Generic Name ___________________________________
Address _____________________________________________
Policy Number ________________________________________
____________________________________________________
Date of Issue _________________ Issue Age _______________
Telephone (
) ____________________________________
Contestable Period Expires _____________________________ __
Date of Birth ________________________ Age _____________
Suicide Period Expires __________________________________
Policy Loan Rate _______________________________________
P P O O L L I I C C Y Y / / R R I I D D E E R R D D E E S S C C R R I I P P T T I I O O N N : :
_
Initial/
(Age) Benefit
Initial/Renewal
(Age) Payable
Policy/Rider Name
Continuing Benefit
From
To
Annual Premium
From
To
Total Initial Annual Premium $ ___________________ Mode of Payment ____________________ Amount $ ____________________
Total Renewal Annual Premium $ ___________________ Mode of Payment ___________________ Amount $ __________________
F5436FL REV. 807
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