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Advisor Name
Client Name
Date of Birth Or Age
Gender
Male
Female
Nicotine
Yes
No
State
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District of Columbia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Occupation /Duties/Specialty
Income
Benefit Amount
Elimination Period
30 Days
60 Days
90 Days
180 Days
365 Days
Benefit Period
2 Years
5 Years
10 Years
To age 65
To age 67
To age 70
Own Occ
Own Occ
Own Occ and not working
Best Available
Other, see notes below
Contract
Non-Can
Guaranteed Renewable (if available)
Both Non-Can and GR (if available)
Riders
Residual
FIO
3% COLA
6% COLA
CAT
MN Discount
FIO Amount
CAT Amount
Other Coverage
Notes: