Variable Life General Request Form

Please complete the following request form to receive a FREE Variable Life Quote. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 
  Your date of birth:     
     Non-Smoker   Smoker

  Spouse's date of birth: 
     Non-Smoker   Smoker
  Would this be a Single Insured or Joint Insured policy?
     Single    Joint

  Do you currently own insurance?            Yes   No

  Are you looking to upgrade this policy?    Yes   No
  Your tax bracket is:
     28%    31%    36%    39.6%    Unknown
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  

  Amount you may want to consider investing: 
     Single    Quarterly    Semi-Annually    Annually

  For how many years (5 years minimum): 

  Your estimated time frame to purchase a universal life policy is?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
  Additional Comments/Questions:


Copyright 1998 Fielder Financial Management, Ltd.
All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.

Disclosure:  For more complete information about variable life, including charges and expenses, obtain a prospectus by calling 1-800-480-7526.   Read it carefully before you invest or send money. Investment return and principal value of an investment will fluctuate.  An investors units, when redeemed, may be worth more or less than their original investment.  Consult your tax advisor.