CPSS - Life Insurance
Who is your SMD?
*
Please Select
Alexis Lakins
Brennan West
Charles Shelton
Ciara Morgan
Dale Bosley
Fidelis Obuzor
Jeff Crothers
Kevin Maginnis
Melanie Kamp
Nathan Wheeler
Nick Bosley
Prime Corporate
Silas LaGoy
Tiffany Gallo
Would you like a copy of this CPSS? If so, please add your email:
example@example.com
Agents on case (use Legal Names and fill out completely):
*
Agent Legal Name:
Agent ID
% Split:
Promotion Level
NPN #:
Last 4 SSN:
Are you licensed/appointed?
Phone number:
Email Address:
How long have you known the insured?
Relationship to Insured:
Is this a Hot State? If so, did you notify your upline?
Writing agent:
TA
A
SA
MD
SMD+
Yes
No (I will apply today)
Agent
Relative
Friend
Yes - Florida
Yes - Virginia
Yes - Alabama
Yes - Georgia
Yes - Kentucky
Yes - Louisiana
Yes - Massachusetts
Yes - Mississippi
Yes - Montana
Yes - New Mexico
Yes - North Carolina
Yes - Pennsylvania
Yes - Puerto Rico
Yes - South Carolina
Yes - South Dakota
Yes - Utah
Yes - Wisconsin
No - It's another state
Split agent:
TA
A
SA
MD
SMD+
Yes
No (I will apply today)
Agent
Relative
Friend
Yes - Florida
Yes - Virginia
Yes - Alabama
Yes - Georgia
Yes - Kentucky
Yes - Louisiana
Yes - Massachusetts
Yes - Mississippi
Yes - Montana
Yes - New Mexico
Yes - North Carolina
Yes - Pennsylvania
Yes - Puerto Rico
Yes - South Carolina
Yes - South Dakota
Yes - Utah
Yes - Wisconsin
No - It's another state
How many individuals are you setting up policies for?
*
Please Select
1
2
3
4
For any of the policies you're setting up, is the policy owner different from the insured person?
*
Please Select
Yes
No
Are you setting up any policies with Symetra?
*
Please Select
Yes
No
Are you setting up any policies with Allianz?
*
Please Select
Yes
No
Do you have any additional riders you are adding to the case?
*
Please Select
Yes - they are on the illustration
No
Insured Information:
*
Insured #1
First Name
Middle Name
Last Name
DOB
Gender
Phone number
Email Address:
Marital Status
SSN
Street name/Unit #
City
State
Zip Code
Years at current address:
Birth State
US Citizen?
If not US Citizen, which country where you born in?
Product #1: Name and coverage amount
Product #2: Name and coverage amount
Product #3: Name and coverage amount
Is this insured also the owner of their policy(ies)?
Insured Information:
*
Insured #1
Insured #2
First Name
Middle Name
Last Name
DOB
Gender
Phone number
Email Address:
Marital Status
SSN
Street name/Unit #
City
State
Zip Code
Years at current address:
Birth State
US Citizen?
If not US Citizen, which country where you born in?
Product #1: Name and coverage amount
Product #2: Name and coverage amount
Product #3: Name and coverage amount
Is this insured also the owner of their policy(ies)?
Insured Information:
*
Insured #1
Insured #2
Insured #3
First Name
Middle Name
Last Name
DOB
Gender
Phone number
Email Address:
Marital Status
SSN
Street name/Unit #
City
State
Zip Code
Years at current address:
Birth State
US Citizen?
If not US Citizen, which country where you born in?
Product #1: Name and coverage amount
Product #2: Name and coverage amount
Product #3: Name and coverage amount
Is this insured also the owner of their policy(ies)?
Insured Information:
*
Insured #1
Insured #2
Insured #3
Insured #4
First Name
Middle Name
Last Name
DOB
Gender
Phone number
Email Address:
Marital Status
SSN
Street name/Unit #
City
State
Zip Code
Years at current address:
Birth State
US Citizen?
If not US Citizen, which country where you born in?
Product #1: Name and coverage amount
Product #2: Name and coverage amount
Product #3: Name and coverage amount
Is this insured also the owner of their policy(ies)?
Insured Identification:
*
Insured #1
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Insured Identification:
*
Insured #1
Insured #2
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Insured Identification:
*
Insured #1
Insured #2
Insured #3
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Insured Identification:
*
Insured #1
Insured #2
Insured #3
Insured #4
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Height/Weight Information
*
Insured #1
Current Height
Current Weight
Weight 1 year ago (only required for children)
Reason for weight change (only required for children)
Height/Weight Information
*
Insured #1
Insured #2
Current Height
Current Weight
Weight 1 year ago (only required for children)
Reason for weight change (only required for children)
Height/Weight Information
*
Insured #1
Insured #2
Insured #3
Current Height
Current Weight
Weight 1 year ago (only required for children)
Reason for weight change (only required for children)
Height/Weight Information
*
Insured #1
Insured #2
Insured #3
Insured #4
Current Height
Current Weight
Weight 1 yearago (only requiredfor children)
Reason for weight change (only required for children)
Owner Information (If different from insured):
Owner #1
Owner #2
Which individual are they the owner for?
First Name
Middle Name
Last Name
Gender
DOB
SSN
Address
Phone number
Birth State
US Citizen?
Marital Status
Email Address:
Years at current address:
Form of ID (DL etc):
State of Issue:
ID Number:
Expiration Date:
Physician Information:
Insured #1
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:
Physician Information:
Insured #1
Insured #2
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:
Physician Information:
Insured #1
Insured #2
Insured #3
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:
Physician Information:
Insured #1
Insured #2
Insured #3
Insured #4
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:
Non-Medical Information (Please select all that apply to you):
Insured #1
NOTES:
Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy?
High blood pressure, heart attack, murmur, palpitation, or anemia or any disease of the heart, blood vessels or blood?
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
Ulcer, colitis, hepatitis, cirrhosis, or any disease of the esophagus, stomach, intestines, rectum, gallbladder or liver?
Treated or counseled forthe use of alcohol, drugs or other substance?
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
Cancer, tumor, polyp or cyst?
Any physical deformity or amputation?
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition?
Any immune deficiency disorder, (AIDS), (ARC), (HIV), or test positive on an AIDS/HIV-related test?
Within the past ten years, have you ever used marijuana, sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
Non-Medical Information (Please select all that apply to you):
Insured #1
Insured #2
NOTES:
Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy?
High blood pressure, heart attack, murmur, palpitation, or anemia or any disease of the heart, blood vessels or blood?
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
Ulcer, colitis, hepatitis, cirrhosis, or any disease of the esophagus, stomach, intestines, rectum, gallbladder or liver?
Treated or counseled for the use of alcohol, drugs or other substance?
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
Cancer, tumor, polyp or cyst?
Any physical deformity or amputation?
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition?
Any immune deficiency disorder, (AIDS), (ARC), (HIV), or test positive on an AIDS/HIV-related test?
Within the past ten years, have you ever used marijuana, sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
Non-Medical Information (Please select all that apply to you):
Insured #1
Insured #2
Insured #3
NOTES:
Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy?
High blood pressure, heart attack, murmur, palpitation, or anemia or any disease of the heart, blood vessels or blood?
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
Ulcer, colitis, hepatitis, cirrhosis, or any disease of the esophagus, stomach, intestines, rectum, gallbladder or liver?
Treated or counseled for the use of alcohol, drugs or other substance?
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
Cancer, tumor, polyp or cyst?
Any physical deformity or amputation?
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition?
Any immune deficiency disorder, (AIDS), (ARC), (HIV), or test positive on an AIDS/HIV-related test?
Within the past ten years, have you ever used marijuana, sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
Non-Medical Information (Please select all that apply to you):
Insured #1
Insured #2
Insured #3
Insured #4
NOTES:
Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy?
High blood pressure, heart attack, murmur, palpitation, or anemia or any disease of the heart, blood vessels or blood?
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
Ulcer, colitis, hepatitis, cirrhosis, or any disease of the esophagus, stomach, intestines, rectum, gallbladder or liver?
Treated or counseled for the use of alcohol, drugs or other substance?
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
Cancer, tumor, polyp or cyst?
Any physical deformity or amputation?
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition?
Any immune deficiency disorder, (AIDS), (ARC), (HIV), or test positive on an AIDS/HIV-related test?
Within the past ten years, have you ever used marijuana, sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
Other than what has already been disclosed, within the past 5 years have you:
Insured #1
NOTES:
Other than what has already been disclosed, within the past 5 years have you:
Had or been advised to have a surgical procedure?
Dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
Injury requiring treatment?
Taking prescription, vitamin, supplement or over-the-counter medication?
Parents, brothers, sisters, ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
Life Application declined, withdrawn, postponed, rated, modified, cancelled?
Pregnant?
Other than what has already been disclosed, within the past 5 years have you:
Insured #1
Insured #2
NOTES:
Other than what has already been disclosed, within the past 5 years have you:
Had or been advised to have a surgical procedure?
Dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
Injury requiring treatment?
Taking prescription, vitamin, supplement or over-the-counter medication?
Parents, brothers, sisters, ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
Life Application declined, withdrawn, postponed, rated, modified, cancelled?
Pregnant?
Other than what has already been disclosed, within the past 5 years have you:
Insured #1
Insured #2
Insured #3
NOTES:
Other than what has already been disclosed, within the past 5 years have you:
Had or been advised to have a surgical procedure?
Dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
Injury requiring treatment?
Taking prescription, vitamin, supplement or over-the-counter medication?
Parents, brothers, sisters, ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
Life Application declined, withdrawn, postponed, rated, modified, cancelled?
Pregnant?
Other than what has already been disclosed, within the past 5 years have you:
Insured #1
Insured #2
Insured #3
Insured #4
NOTES:
Other than what has already been disclosed, within the past 5 years have you:
Had or been advised to have a surgical procedure?
Dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
Injury requiring treatment?
Taking prescription, vitamin, supplement or over-the-counter medication?
Parents, brothers, sisters, ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
Life Application declined, withdrawn, postponed, rated, modified, cancelled?
Pregnant?
If any of the boxes above are checked, please provide details below for each medical condition:
Condition 1
Condition 2
Condition 3
Condition 4
Medical Condition
Date Diagnosed
Duration
Treatments
Results of treatment
Medication
Dosage
Frequency
Doctor Name/address of whose providing treatment
Family History (only required for Symetra policies): **If additional siblings exist, please enter in the notes section.
Living/Deceased
Age
Current Health
Father
Living
Deceased
Mother
Living
Deceased
Brother
Living
Deceased
Brother
Living
Deceased
Brother
Living
Deceased
Sister
Living
Deceased
Sister
Living
Deceased
Sister
Living
Deceased
Source of Funds:
Please Select
Annuity Contract
Business Income
Charitable Donation/Church
Death Benefit
Earned Income
Inheritance
IRA
Money Market Fund
Other
Other Life Insurance Policy
Property Income
Qualified Funds
Sale of Property
Savings
Settlement/Legal Proceeds
Source of Wealth:
Please Select
401(k)
Annuity
Business Income (includes sale of business)
Earned Personal Income
Employee Stock Ownership
Inheritance/Gift
IRA
Investments
Life Insurance Proceeds
Lottery
Pension
Property Income (includes sale of property)
Retirement Income
Settlement/Legal Proceeds
Total Household Liquid Assets:
Within the Last 2 years have you:
Insured 1:
NOTES:
Used any Nicotine?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Do you participate in Regular weekly exercise?
Do you participate in Athletics?
Do you have pets?
Do you get regular exams by your physician?
Do you get regular Dental Checkups?
Are you a member of a social group or volunteer for charity work?
Within the Last 2 years have you:
Insured 1:
Insured 2:
NOTES:
Used any Nicotine?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Do you participate in Regular weekly exercise?
Do you participate in Athletics?
Do you have pets?
Do you get regular exams by your physician?
Do you get regular Dental Checkups?
Are you a member of a social group or volunteer for charity work?
Within the Last 2 years have you:
Insured 1:
Insured 2:
Insured 3:
NOTES:
Used any Nicotine?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Do you participate in Regular weekly exercise?
Do you participate in Athletics?
Do you have pets?
Do you get regular exams by your physician?
Do you get regular Dental Checkups?
Are you a member of a social group or volunteer for charity work?
Within the Last 2 years have you:
Insured 1:
Insured 2:
Insured 3:
Insured 4:
NOTES:
Used any Nicotine?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Do you participate in Regular weekly exercise?
Do you participate in Athletics?
Do you have pets?
Do you get regular exams by your physician?
Do you get regular Dental Checkups?
Are you a member of a social group or volunteer for charity work?
Background and Activities (If yes, please provide notes in the notes section):
Insured 1
Notes:
Are you a pilot?
Are you a member, or have you entered into a written agreement to become a member, of any armed forces, including reserves?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Rodeo
Organized Racing
Mountain Climbing
Competitive Skiing
Skydiving
DL Violation in the past 5 years?
Felony/Misdem?
Do you have any plan to travel outside of the US in the next year?
Background and Activities (If yes, please provide notes in the notes section):
Insured 1
Insured 2
Notes:
Are you a pilot?
Are you a member, or have you entered into a written agreement to become a member, of any armed forces, including reserves?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Rodeo
Organized Racing
Mountain Climbing
Competitive Skiing
Skydiving
DL Violation in the past 5 years?
Felony/Misdem?
Do you have any plan to travel outside of the US in the next year?
Background and Activities (If yes, please provide notes in the notes section):
Insured 1
Insured 2
Insured 3
Notes:
Are you a pilot?
Are you a member, or have you entered into a written agreement to become a member, of any armed forces, including reserves?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Rodeo
Organized Racing
Mountain Climbing
Competitive Skiing
Skydiving
DL Violation in the past 5 years?
Felony/Misdem?
Do you have any plan to travel outside of the US in the next year?
Background and Activities (If yes, please provide notes in the notes section):
Insured 1
Insured 2
Insured 3
Insured 4
Notes:
Are you a pilot?
Are you a member, or have you entered into a written agreement to become a member, of any armed forces, including reserves?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Rodeo
Organized Racing
Mountain Climbing
Competitive Skiing
Skydiving
DL Violation in the past 5 years?
Felony/Misdemeanor?
Do you have any plan to travel outside of the US in the next year?
Existing Coverage:
Insured 1
Do you have insurance inforce or pending? (If yes, please answer the following questions)
Company Name(s)
Policy # (If known)
Amount of Coverage
Issue year
What type of insurance is it?
WiIl this be a replacement?
Are we doing a 1035 exchange? If yes, for what amount?
Existing Coverage:
Insured 1
Insured 2
Do you have insurance inforce or pending? (If yes, please answer the following questions)
Company Name(s)
Policy # (If known)
Amount of Coverage
Issue year
What type of insurance is it?
WiIl this be a replacement?
Are we doing a 1035 exchange? If yes, for what amount?
Existing Coverage:
Insured 1
Insured 2
Insured 3
Do you have insurance inforce or pending? (If yes, please answer the following questions)
Company Name(s)
Policy # (If known)
Amount of Coverage
Issue year
What type of insurance is it?
WiIl this be a replacement?
Are we doing a 1035 exchange? If yes, for what amount?
Existing Coverage:
Insured 1
Insured 2
Insured 3
Insured 4
Do you have insurance inforce or pending? (If yes, please answer the following questions)
Company Name(s)
Policy # (If known)
Amount of Coverage
Issue year
What type of insurance is it?
WiIl this be a replacement?
Are we doing a 1035 exchange? If yes, for what amount?
Beneficiary Information (Insured #1):
*
Name
DOB
SSN
Address
%
Relationship to the Insured
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3
Beneficiary Information (Insured #2):
*
Name
DOB
SSN
Address
%
Relationship to the Insured
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3
Beneficiary Information (Insured #3):
*
Name
DOB
SSN
Address
%
Relationship to the Insured
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3
Beneficiary Information (Insured #4):
*
Name
DOB
SSN
Address
%
Relationship to the Insured
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3
Employment Information:
*
Insured 1
Employer
Position
Address
Phone Number
Annual Income
Net worth
Employment Information:
*
Insured 1
Insured 2
Employer
Position
Address
Phone Number
Annual Income
Net worth
Employment Information:
*
Insured 1
Insured 2
Insured 3
Employer
Position
Address
Phone Number
Annual Income
Net worth
Employment Information:
*
Insured 1
Insured 2
Insured 3
Insured 4
Employer
Position
Address
Phone Number
Annual Income
Net worth
Bank Information:
*
Insured 1
Payors Name
Initial Planned Premium
Is there a lump sum amount?
Frequency
Draft Date (policy effective date is preferred)
Bank Name
Checking or Savings?
Routing #
Account #
Are you submitting money with the application?
Bank Information:
*
Insured 1
Insured 2
Payors Name
Initial Planned Premium
Is there a lump sum amount?
Frequency
Draft Date (policy effective date is preferred)
Bank Name
Checking or Savings?
Routing #
Account #
Are you submitting money with the application?
Bank Information:
*
Insured 1
Insured 2
Insured 3
Payors Name
Initial Planned Premium
Is there a lump sum amount?
Frequency
Draft Date (policy effective date is preferred)
Bank Name
Checking or Savings?
Routing #
Account #
Are you submitting money with the application?
Bank Information:
*
Insured 1
Insured 2
Insured 3
Insured 4
Payors Name
Initial Planned Premium
Is there a lump sum amount?
Frequency
Draft Date (policy effective date is preferred)
Bank Name
Checking or Savings?
Routing #
Account #
Are you submitting money with the application?
Additional Notes:
Illustration:
*
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Agent Acknowledgement: I affirm that I have completed this CPSS form in its entirety. I understand that any missing or incomplete information may cause delays in submission. I will also review my LICENSE & APPOINTMENT report in myWFG to ensure that I am properly licensed and appointed in the applicable state, along with the split agent.
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