Hey there team twa!

Let's get your Biz Submitted..

Remember.. the form must be submitted to save all the information. Prepare the client and yourselves to have all the information needed to complete the Submission.

TIP: If there is a required field that absolutely cannot be collected at time of Submission.. enter (in progress), if the field requires a numeric response enter (000)

Fill the New Business Submission Form

Check in with our Case Manager to ensurely timely processing.

Kick back and relax.. but do spot check...

NEW BUSINESS SUBMISSION

Policy Owner Information

Is the Policy Owner the same as the Insured on the Policy? *

Policy Owner's First Name *

Policy Owner's Last Name *

Policy Owner's Date of Birth *

Social Security/ Tax ID Number *

Policy Owner's Phone Number *

Policy Owner's Email *

Policy Owner's Address

Address

Street Address *

City

State

Country

Postal code

ID Number , Include Issuing Government Agency *

If available, upload ID here

Place of Birth, if within the United States, enter State *

Insured's Information

Insured's Relationship to Policy Owner *

Insured's Full Name *

Insured's Phone Number *

Insured's Email *

Insured's Address,if same as the Policy Owner's,enter "Same" *

Insured's Date of Birth *

Insured's Social Security / Tax ID Number *

Gender *

Marital Status *

Insured's ID Number, Include Issing Govt.Agency *

Upload Insured's ID, if available

Insured's Place of Birth, if born in United States, enter the State *

Household Information

Name of Employer, **if Retired, enter: Retired *

Occupation *

Total Years/Months with Employer *

Annual Income *

Insured's Family Information

(For Underwriting)

Family Information, include Mother, Father, Age, and Status *

Beneficiaries *

Medical Information

Insured's Height *

Insured's Weight *

Tobacco Use *

Physician's Name *

Physician's Phone Number *

Physician's Address *

Last Date of Visit, Reason, and Result *

Taking Medication? *

Additional Medical Information *

Labs Ordered? *

If Ordered, select Vendor

Barcode Number of Lab, if still pending: enter "Pending"

Plan Information

Has a case request been submitted? *

Carrier Choice *

Death Benefit Applied for *

Funding with Lump Sum?

None
External 1035 Exchange
Internal 1035 Exchange
Non 1035x Lump Sum

Mode of Payment *

Payment Amount *

Is this a policy replacement? *

Originating Agent *

Writing Field Agent *

Upline for Originating Agent Here *

Agent- Reporting Notes *

Replacement Information

Does the Insured have Life or Annuity Policy? *

Life Insurance Information

Life Insurance Carrier

Life Insurance Policy Type

Death Benefit Amount

Approximate Issue Year

Annuity Information

Annuity Insurance Carrier

Annuity Policy Type

Amount Invested

Approximate Issue Year

If Multiple, list the information below..

Payment Information Details

Bank Name *

Routing Number *

Account Number *

Recurring Draft Date (1st-28th) *

Initial Pay Option *

Policy Owner Signature, if available

Clear

Insured's Signature, if available

Clear

Optional Uploads

eg. Voided Check, FNA, Policies, Statements, etc.

Captcha

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