Limitless CPSS - Life Insurance

Who is your SMD?

Who is your trainer?

Would you like a copy of this CPSS? If so, please add your email:

example@example.com

Is this your first time submitting business as a Writing Agent with our Ops team?

Agents on case (use Legal Names and fill out completely):

Rows	Agent Legal Name:	Agent ID	% Split:	Promotion Level	NPN #:	Last 4 SSN:	Are you licensed/appointed in the applicant state?	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:
Split agent:

How many individuals are you setting up policies for?

For any of the policies you're setting up, is the policy owner different from the insured person?

Are you setting up any policies with Symetra?

Are you setting up any policies with Allianz?

Do you have any additional riders you are adding to the case?

Please list riders selected

Insured Information:

Rows	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:

Rows	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:

Rows	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:

Rows	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:

Rows	Insured #1
Form of ID:
State of Issue:
ID Number:
Expiration Date:

Insured Identification:

Rows	Insured #1	Insured #2
Form of ID:
State of Issue:
ID Number:
Expiration Date:

Insured Identification:

Rows	Insured #1	Insured #2	Insured #3
Form of ID:
State of Issue:
ID Number:
Expiration Date:

Insured Identification:

Rows	Insured #1	Insured #2	Insured #3	Insured #4
Form of ID:
State of Issue:
ID Number:
Expiration Date:

Height/Weight Information

Rows	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

Rows	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

Rows	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

Rows	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):

Rows	Owner #1	Owner #2
Which individual are they the owner for?
Relationship to the insured
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:
Employer
Job title
Annual personal income
Annual household net worth
Total in force life insurance

Physician Information:

Rows	Insured #1
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:

Physician Information:

Rows	Insured #1	Insured #2
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:

Physician Information:

Rows	Insured #1	Insured #2	Insured #3
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:

Physician Information:

Rows	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):

Rows	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):

Rows	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):

Rows	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):

Rows	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:

Rows	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:

Rows	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:

Rows	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:

Rows	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:

Rows	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.

Rows	Living/Deceased	Age	Current Health
Father
Mother
Brother
Brother
Brother
Sister
Sister
Sister

Source of Funds:

Source of Wealth:

Total Household Liquid Assets:

Tobacco/Nicotine/Marijuana Usage:

Rows	Insured 1:	NOTES:
Used any Nicotine in any form?
Used any Marijuana in any form?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Date last used

Tobacco/Nicotine/Marijuana Usage:

Rows	Insured 1:	Insured 2:	NOTES:
Used any Nicotine in any form?
Used Marijuana in any form?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Date last used

Tobacco/Nicotine/Marijuana Usage:

Rows	Insured 1:	Insured 2:	Insured 3:	NOTES:
Used any Nicotine in any form?
Used Marijuana in any form?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Date last used

Tobacco/Nicotine/Marijuana Usage:

Rows	Insured 1:	Insured 2:	Insured 3:	Insured 4:	NOTES:
Used any Nicotine in any form?
Used Marijuana in any form?
If you have used nicotine/please enter the form and frequency of use in the notes section:
Date last used

Background and Activities (If yes, please provide notes in the notes section):

Rows	Insured 1	Notes:
Are you in the Military?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Are you separating from the Military? If yes please provide date of separation and current employment information.
Are you a pilot?
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):

Rows	Insured 1	Insured 2	Notes:
Are you in the Military?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Are you separating from the Military? If yes please provide date of separation and current employment information.
Are you a pilot?
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):

Rows	Insured 1	Insured 2	Insured 3	Notes:
Are you in the Military?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Are you separating from the Military? If yes please provide date of separation and current employment information.
Are you a pilot?
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):

Rows	Insured 1	Insured 2	Insured 3	Insured 4	Notes:
Are you in the Military?
Are you on standby to go to, or have deployment orders for, a location outside of the U.S.?
Which country?
Are you separating from the Military? If yes please provide date of separation and current employment information.
Are you a pilot?
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:

Rows	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:

Rows	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:

Rows	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:

Rows	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):

Rows	Name	DOB	SSN	Address	%	Relationship to the Insured	If Trust Date Established	If Trust Trustee Name	If Trust EIN/Tax ID
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3

Beneficiary Information (Insured #2):

Rows	Name	DOB	SSN	Address	%	Relationship to the Insured	If Trust Date Established	If Trust Trustee Name	If Trust EIN/Tax ID
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3

Beneficiary Information (Insured #3):

Rows	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):

Rows	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:

Rows	Insured 1
Employer
Position
Address
Phone Number
Annual Income
Net worth
Length Of Employment

Employment Information:

Rows	Insured 1	Insured 2
Employer
Position
Address
Phone Number
Annual Income
Net worth
Length Of Employment

Employment Information:

Rows	Insured 1	Insured 2	Insured 3
Employer
Position
Address
Phone Number
Annual Income
Net worth
Length Of Employment

Employment Information:

Rows	Insured 1	Insured 2	Insured 3	Insured 4
Employer
Position
Address
Phone Number
Annual Income
Net worth
Length Of Employment

Bank Information:

Rows	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:

Rows	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:

Rows	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:

Rows	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, Identification Documents, Cover Letter, ETC:

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.