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Permanent Life Quote Request

Permanent Life Quote

Broker Information
Agent Name*
First Last
Email*
Phone Number*
Cell Phone
Fax
Client Information
Applicant's Date of Birth
MM slash DD slash YYYY
Applicant's Name
First Last
Applicant's Sex
- Female
- Male
Tobacco History
Current or date of last use:
Quote a preferred class on the applicant?
- Yes
- No
Quote Information
State of quote
Primary objective
- Death Benefit
- Cash Accumulation
- Retirement Income
Other objectives / needs
- Key Man
- Family Protection
- Buy Sell
- Loan / Debt Repayment
- Other
If "Other' please explain:
Face amounts(s)
Specified carrier
Product Information
Payment Mode
- Single Premium
- Full Pay
- Short Pay
Plan Type
- Universal Life
- Index UL
- Survivorship UL
Permanent - Desired Interest Rate
Permanent - Alternate Interest Rate
Short Pay Options
Suspend Pay - At age
Suspend Pay - In Specific Year
Payment Mode
- Annual
- Semi-Annual
- Quarterly
- Monthly
Additional Premiums
1035 Exchange
Lump Sum
Death Benefit Option
- Level
- Increasing
Riders
Riders - Waiver of Premium
- Yes
- No
Riders - Accidental Death Benefit
- Yes
- No
Specify Amount:
LTC Rider
- 2%
- 4%
Other Rider:
Case Information
Are you in competition for this case?
- Yes
- No
If yes, please specify:
Additional comments or health concerns?

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Occidental Underwriters of Hawaii, Ltd.
1163 South Beretania Street
Honolulu, Hawaii 96814
Phone: (808) 536-1933
Fax: (808) 527-8810

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