Fillable Form Lu1312 - New Business Transmittal printable pdf download

Form Lu1312 - New Business Transmittal

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New Business Transmittal Form

Banner Life Insurance Company

3275 Bennett Creek Avenue

Frederick, Maryland 21704

(800) 638-8428

Transmittal Date ______________________________

Policy # ______________________________________

Case Manager Name __________________________________

Case Manager Email _____________________

BGA Number ______________________

BGA Name _____________________________________________

Agent Number _____________________

Agent Name ____________________________________________

Proposed Insured Name ____________________________ DOB _______________ Last 4 SSN _____________

> Product:

OPTerm

 10

 15

 20

 30

 Life Step

> Face Amount $ _____________ 1035 $ ________________ Hold Policy At Issue?  Yes  No

New

> Rider(s) (type and amount) __________________________________________________________

Application

> Temporary Insurance Requested?  Yes

 No

Check Enclosed? $ _____________________

(complete

Draft Initial Premium?

 Yes  No

for first

submission

> Quote Class:

 Preferred Plus

 Preferred

 Standard Tobacco

only)

 Preferred Tobacco

 Standard Plus

 Standard

 Substandard Table __________________

 Flat Extra _________________

> If you are planning to use this application for more than one policy on the same applicant, indicate

amount and plan _________________________________________________________________

> If this application should be held at issue for a companion case, indicate name(s) of Proposed

Insured _________________________________________________________________________

Underwriting Requirements Enclosed

APS Order:  Agency

 HO

IR Order:  Agency

 HO

Dr. Name(s): ___________________________________________

 Application

 Employer Owned Consent

 Paramed

 Agent Report

 HIPAA

 Premium Check

 Accelerated Death Benefit Disc

 Illustration

 Questionnaires

 APS

 Inspection Report

 Replacement Form

 Authorization

 Motor Vehicle Report

 Temporary Ins Agreement

 Disclosure(s) _________________

 MD Exam

 Trust Certification

 EKG

 Non-Med

 1035 Forms

 Notice Consent

 Other ______________

Delivery Requirements Enclosed

 Amendment

 EFT Form and Void Check

 Initial Premium Check

 Application - updated Signature

 Good Health Statement

 Trust Document

 Delivery Receipt

 Illustration

Special Instructions

LU1312 (3-15)

Form Lu1312 - New Business Transmittal

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