Premium Financial Advisors Inc.
CPS Insurance Services		   Premium Financail Advisors Inc.

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

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Proposal Request From

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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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