New Business Report

1
What is your NPN?* This field is required.
2
Client's Legal Name* This field is required.This is the name on all official documents including proof of identity and application.
First Name
Last Name
3
Enter Client's Preferred Name
4
Enter Client's Phone Number* This field is required.
Please enter a valid phone number.
5
Enter Client's Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Enter Client's EmailLeave Blank if none
example@example.com
7
What is the Date of Application?* This field is required.
Date
Month
Day
Year
8
Which carrier are you submitting today?* This field is required.
Aetna
Aflac
AIG/Corebridge
Allstate
Ambetter ACA
American Amicable
American Equity
Anthem
BCBS of SC
Capital Blue Cross
CareSource
Cigna
Citizens
Devoted
Fidelity & Guaranty Life
Foresters
GPM
GTL
Highmark
Humana
Kaiser
Manhattan Life
Medico/Wellabe
Molina
MoO
NassauRe
NCD
NLG
Physicians Mutual
Royal Neighbors
Sentara
Silac
Transamerica
UnitedHealthcare
Wellcare
Wellpoint
Other
9
What AmAm product are you submitting?* This field is required.
Please Select
Please Select
SafeCare Term
Home Protector
Platinum Solutions
American Legacy
Senior Choice
Family Choice
Easy Term
Express UL
SecureLife Plus
Security Protector
Term Made Simple
Survivor Protector
Other
10
What F&G product are you submitting?* This field is required.
Please Select
Please Select
Annuity
Life Pathsetter
Life Everlast
Other
11
What Foresters product are you submitting?* This field is required.
Please Select
Please Select
Strong Foundation
Your Term
Smart UL
Advantage Plus II
Prepared II
Bright Future
PlanRight
Other
12
What NLG product are you submitting?* This field is required.
Please Select
Please Select
Annuity
FIT Select Income
Term
Flex Life
Peak Life
Other
13
What AIG/Corebridge product are you submitting?* This field is required.
Please Select
Please Select
SIWL Immediate
SIWL Graded
Guaranteed Issue
Other
14
What Aetna product are you submitting?* This field is required.
Please Select
Please Select
Final Expense
Hospital Indemnity
Cancer Plan
Heart Attack
Short Term Care
MA Only
MAPD
PDP
MedSupp
Other
15
What Medico/Wellabe product are you submitting?* This field is required.
Please Select
Please Select
Dental
First Diagnosis
Hospital Indemnity
MedSupp
Other
16
What MoO product are you submitting?* This field is required.
Please Select
Please Select
Term Life Express
Living Promise
Child Whole Life
Accidental Death
IUL Express
IUL
UL
Term Life Answers
Critical Illness
Other
17
What Citizens product are you submitting?* This field is required.
Please Select
Please Select
Final Expense
Other
18
What Transamerica product are you submitting?* This field is required.
Please Select
Please Select
Immediate Solutions
Trendsetter
Other
19
What GPM product are you submitting?* This field is required.
Equity Protector
Please Select
Equity Protector
Whole Life
Other
20
What Royal Neighbors product are you submitting?* This field is required.
Please Select
Please Select
Legacy Final Expense
Term Life
Other
21
What Allstate product are you submitting?* This field is required.
Please Select
Please Select
Fixed-Benefit Indemnity
Senior Indeminity
Dental
Short Term Medical
Accidental
Other
22
What NCD product are you submitting?
Please Select
Please Select
Dental
Other
23
What Manhattan Life product are you submitting?
Please Select
Please Select
Cancer/Heart Attack/Stroke
Dental
Home Healthcare
Short Term Care
Other
24
What Kaiser product are you submitting?
Please Select
Please Select
MAPD
Other
25
What Physician's Mutual product are you submitting?
Please Select
Please Select
Dental
MedSupp
Other
26
What product are you submitting?* This field is required.
Please Select
Please Select
ACA
CSNP
DSNP
MA Only
MAPD
MedSupp
PDP
Other
27
What product did you submit?* This field is required.
28
What is the Monthly Premium?* This field is required.If there is no premium(i.e. a Medicare or ACA plan), please put 0 (Zero).
29
What is the frequency of payment?If there is no premium(i.e. a Medicare or ACA plan), please put 'Monthly.'
Monthly
Quarterly
Semi-Annual
Annual
Single Premium
30
Any Special notes or remarks?
Should be Empty: