Trans America Immediate Solutions Sample App 2
P. 1
Agent Name : Brad Smith
Is this your first time writing with this carrier?
Agent Mobile Phone : Insured’s Name : Monthly Premium : Carrier :
Date
: 04/14/2015 09:00 AM : Paul Huneycutt
: Lincoln/AR
: $424.80
: Immediate Solutions/ WL/ Simplifed Issue
From
:
APV Amount TransAmerica Product
A Lead; Rewrite; Final Expense Lead
OFFICIAL USE ONLY : Date Received : Check included w/application Corrections Needed :
:
Date Submitted to Carrie : Scanned by :
Paula Randall $35.40
Agent Direct Manager
Insured’s City/State
New Business Transmittal Form
:
No
Agent called by
:
Time :
