CPSS - Life Insurance

Who is your SMD?

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

example@example.com

Agents on case

Rows	Agent Legal Name	Agent ID	Promotion Level	NPN#:	Last 4 SSN:	Are you licensed/appointed?	Phone number/Email	Relationship to Insured	Did you notify your upline if it's a hot state ? (Hot Stated in dropdown)
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?

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

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

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 aoverage 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 aoverage 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 aoverage 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 aoverage 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	Insured #5
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 aoverage 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:

Insured Identification:

Rows	Insured #1	Insured #2	Insured #3	Insured #4	Insured #5
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 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	Insured #5
Current Height
Current Weight
Weight 1 year ago (only required for 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?
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:

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:

Physician Information:

Rows	Insured #1	Insured #2	Insured #3	Insured #4	Insured #5
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result: