Buy Sell Proposal Request Form

Producer Information

Producer Name:*

First Last

Producer Company Name:*

Address*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax

Email:

Producer Broker Dealer or National Account Affiliation:

Send proposal to:

Case Information

Business Name*

State Located*

Type of Industry*

Years in Operation*

Type of Entity

Personal Services
Professional Services
Non-Service Business

Owners

Name	Gender	Tobacco Use?	Date of Birth	Income	% Owner	Benefit Amt.

Less than 10% ownership or more than 10 partners will not be considered for Buy/Sell coverage.

Use + and - icons to add/remove partners. Maximum of 10 rows.

Case Design

Total Business Value*

Benefit Payment Options*

Monthly Installment - Amount

Down Payment - Amount

Monthly Installment - Payout Options

2 Years
3 Years
5 Years

Down Payment - Payout Options

2 Years
3 Years
5 Years

Elimination Period*

365 Days
540 Days
730 Days

Future Purchase Option

Yes
No

Other Case Design Info

If any owners currently have Buy Sell coverage inforce, please indicate who and how much:

Replacing

Yes
No

Is There Competition in the Case?

Yes
No

If Yes, Provide Details

Check with underwriting regarding the following medical conditions:

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Capitas - Buy Sell Proposal Request

Producer Information

Case Information

Owners

Case Design