Client Info
Please fill out the client information below and we will contact you to discuss your case within two business days
Agent/Advisor Name
*
First Name
Last Name
Agent/Advisor Email
*
example@example.com
Client Name
*
First Name
Last Name
Have you heard about premium financing yet?
*
Please Select
Yes
No
Type of Design Requested
*
Please Select
Borrow 100% of premium and pay interest only
Pay fixed $50k/year x 10 years
Pay fixed $100k/year x 10 years
Pay fixed $150k/year x 10 years
Pay fixed $200k/year x 10 years
Pay fixed $250k/year x 10 years
Pay fixed $300k/year x 10 years
Pay fixed $350k/year x 10 years
Pay fixed $400k/year x 10 years
Pay fixed $450k/year x 10 years
Pay fixed $500k/year x 10 years
Age you want income drawdowns from policy to start
*
Purpose of policy
*
Please Select
Personal Estate Planning
Key-Man Insurance (business)
Buy-Sell Insurance (business)
Other (please explain below in notes section)
Citizenship
*
Please Select
US Citizen
Foreign National
Foreign National with Green Card
Foreign National with Visa
Policy Ownership
*
Please Select
Individual-Owned
Trust-Owned
LLC-Owned
S-Corp Operating Company-Owned
Other-explain notes section below
What state is the Policy Owner Domiciled in?
*
Biological Gender
*
Please Select
Male
Female
Other
Age or DOB (DOB is recommended)
*
Smoker/Non Smoker
*
Please Select
Smoker
Non-Smoker
Projected Health Rating
*
Please Select
Super Preferred / Elite
Preferred
Standard
Table B
Table C
Table D
Table E
Table F
Marital Status
*
Please Select
Single
Married
Current Annual Income (household)
*
Total Net Worth (household)
*
Liquid Net Worth (NOT Including 401k or IRA Values)
*
Willing to move AUM collateral to the lender in order to get a lower borrowing rate?
*
Please Select
Yes
No
Gross Real Estate Value
Mortgage Debt on Real Estate
1035 Amount to be transferred to new policy (if any)
*
Any current life insurance policies in force?
Please Select
Yes
No
Im not sure
If yes, what carrier(s) and what death benefit amount(s)?
List any carriers you do NOT want us to use. We will select the best carrier for this particular case NOT including the one(s) you list below.
*
If this is the first time you have submitted a request for a case discussion with Lionsmark Capital, please tell us who referred you to us.
Notes
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