VIRGIL VOEGELE INSURANCE SERVICES Fax #701-873-2701HIGHLIGHT THIS PAGE TO PRINT! THANK YOU!
Insured__________________________________ Birthdate_______________________________
Ht________ Wt_________ Occupation__________________________ Tobacco Use - No - Yes (Kind___________________)
Family History (Parents & Siblings - Cancer, Heart Problems, Diabetes, etc)_______________________________________________
Spouse__________________________________ Birthdate_______________________________
Ht________ Wt_________ Occupation__________________________ Tobacco Use - No - Yes (Kind___________________)
Family History (Parents & Siblings - Cancer, Heart Problems, Diabetes, etc)_______________________________________________
UL - Option 1 or 2 Term 10 - 15 - 20 - 30 Whole Life 2nd to Die Return of Premium Term 15 - 20 - 30
Face amount or premium amount $______________________________________
Riders: Waiver of Premium Child Rider (amount $___________________)
Guaranteed Insurability (amount $__________________) Other____________________________
Daily Benefit $_______________ Elimination__________ HHC $___________________
Riders: Compounding Simple Indemnity 10-pay Single Pay Survivor Benefit Shortened Benefit
Full Non Forfeiture Other________________________________________________________
Number of Children and Ages_____________________________________________________________
Deductible__________________ Co-Insurance____________________________________
Riders: Presc Drug Acc Medical Maternity
Income (net)______________________ Max Benefit or Amount Requested $___________________________
Elimination_____________________ Benefit Length_______________________________
MEDICAL CONDITIONS AND MEDICATIONS________________________________________________________________________
Requested By_____________________________________________________ Date________________________________