subject_line
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
*
Male
Female
9. Health Rating
*
Super Preferred
Preferred
Standard
Table B
10. Secondary Insured
Leave blank unless survivorship. If applicable, provide name, age, sex and health rating.
11. Focus of financial strategy
*
General wealth transfer
Qualified plan protection
Premium financing
Business planning
Retirement planning
College Funding
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.
*
Agree
Disagree
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