CPS Life Settlement Viability Request
Agent Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Client Name
*
First Name
Last Name
Client Age
*
Client Gender
*
Male
Female
Death Benefit
*
Policy Type #1
Convertible Term
Universal Life
Whole Life
Policy #1 Convertible Term Conversion Date
-
Month
-
Day
Year
Date
Policy #1 Universal Life Cash Value (if known)
Policy #1 Whole Life Cash Value (if known)
Policy Type #2
Convertible Term
Universal Life
Whole Life
Policy #2 Convertible Term Conversion Date
-
Month
-
Day
Year
Date
Policy #2 Universal Life Cash Value (if known)
Policy #2 Whole Life Cash Value (if known)
Client Health Scale
*
Very Poor
1
2
3
4
Good
5
1 is Very Poor, 5 is Good
Notes
Submit
Should be Empty: