Obtain a tentative offer for a case that involves Smoking
by completing the form below:

* required information
**Please use TAB key to proceed to the next question field,
not the ENTER key.**

1.*Agent Name :
*Address :
*City :
*State :
*Zip :
*Agent E-Mail:
Agent Phone :
2. Applicant's Name:
Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Have you ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use?
(Select all that apply)
Cigarettes  Cigar  Pipe  Other

How much?
When did you stop?

3. Additional Comments?