NextPoint New Business Form

1. Your First Name *

2. Your Last Name *

3. Your Email *

4. Your Phone *

5. Insured Name *

6. Insured State *

7. Age or DOB *

8. Gender *

9. Health Rating *

10. Secondary Insured

11. Focus of financial strategy *

12. Additional comments

13. I agree to place the name and agent code of one or more designated NextPoint representatives on the application for a total of 35% as co-agents with me. I understand strategies may change as the case develops and I agree to share with NextPoint for 35% regardless of the ultimate strategy employed. *