Premium Financial Advisors Inc.

Premium Financail Advisors Inc.

3456 E. 17th Street, Suite 205, Idaho Falls, Idaho 83406
Telephone: (208) 542-5273 Fax: (208) 542-2978

Life Insurance Premiums

Life Insurance

Premium Financing

Proposal Request From

Premium Financing Support

Premium Financial Advisors Inc. Proposal Request Form

Client Information

Name:
Birth Date:
Spouse's Name:
Spouse's Birth Date:
State of Residency:
Face Amount:

Policy Information

Type of Illustration:	Interest Paid Accrual Rollout Bridge Gap Funding
Interest Amount to be Paid:
Rating:	Preferred Standard Smoker
Total Face Amount of Existing Policies:
Will there be a 1035 exchange?:	Yes No
If Yes, what amount?:

Proposed Owner / Trust / Corporation Information / Charity:

Full Name of Owner / Trust / Corporation / Charity:
Owners Relationship to Proposed Primacy Insured:
Owner's Date of Birth:
Owner's Phone Number:
Owner's Address:	Include Address, City, State, and ZIP
Address of Trust / Corporation:	Include Address, City, State, and ZIP
Trust Contact Name:
TAX ID:
Date of Trust:
Type of Trust:	Revocable Irrevocable
Purpose of Trust:
State of Incoporation:
Name of Trustee / Corporate Officer:
Does the Above Trustee Have Sole Authority to Act on Behalf of the Trust?:	Yes No

Agent Information:

Agency:
Agent:
Correspondence Address:	Include Address, City, State, and ZIP
Phone Number:
Fax Number:
E-mail:

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