Page 32 - Prestige Brochures & Enrollment Packet

LIFE INSURANCE

Name: _____________________________

20-Year Term Life Insurance Enroll Waive

Check the box for the amount of 20-Year Term Life Insurance you want:

$25,000 Are You A:
$50,000
$75,000 Non-Smoker Smoker
$100,000
$125,000
$150,000

Enter Weekly Premium From Rate Sheet: $__________________

Check this box If you would like us to contact you about Life Insurance for your Spouse or Children

Universal Life Insurance Enroll Waive

Check the box for the amount of Universal Life Insurance you want:

$25,000
$50,000 Are You A:

$75,000 Non-Smoker Smoker
$100,000
$125,000
$150,000

Enter Weekly Premium From Rate Sheet: $__________________

Check this box If you would like us to contact you about Life Insurance for your Spouse or Children

Beneficiary Information

Please enter the following information if you would like to designate someone as the beneficiary of your
life insurance (may split up top two people):
Beneficiary Name: Beneficiary Name:

Beneficiary Beneficiary
Address: Address:
Date of Birth: Date of Birth:
Beneficiary Phone: Beneficiary Phone:

Relationship to Relationship to
Beneficiary: Beneficiary:
Percentage (%) to Percentage (%) to
this Beneficiary this Beneficiary

Beneficiaries should not be children under the age of 18. Beneficiaries can be added or changed
anytime. 2