Opportunity Concepts - Policy Audit Qualifier Form

Policy Information - enter information as it applies to the current policy Policy Type Whole Life Universal Life Variable Life Term Life Insured Single Life Survivorship Life Smoker yes no Age at issue if survivorlife, enter second insured's age Class Issued preferred standard rated if rated, enter rating information: Sex   male female(for survivorship polciies, use female) Carrier Issue Date Death Benefit   For UL : Increasing Death Benefit Level Death Benefit Cash Value Annual Premium Loans     Current Information Current Health Class preferred standard rated     Tobacco use non-tobacco user occasional smoker chews Age (if survivor, give age of youngest insured) Other changes in circumstances: Client Objective: Requestor Information Name: Email Relationship to Insured agent/broker advisor trustee insured