Estimate Request Form

Your information will be submitted to Premium Administration for follow-up.  If you would like to receive your Fee Estimate via email, please ensure a valid email addresses is entered.  If you are uncomfortable providing this information over the internet you can fill out the form and FAX it to us at: (480) 922-5283

* marks mandatory fields 

First Name *:  

Last Name *:

Address1 *:

Address2:

City *:

State *:     Zipcode *:

Telephone *:

Fax:

E Mail:

Requestor is *: Trustee Trustor Other

How many policies are owned by the trust? *

Are any of the policies TERM insurance? * Yes  No   Don't Know

Do any of the policies have an active Automatic Loan? * Yes  No   Don't Know
 
What is the total amount of insurance owned by the trust? *
(enter unknown if amount is not known)

How many beneficiaries? *

Does the trust have 5+5 provisions? * Yes  No   Don't Know

Is this a specialty trust? *
(Split Dollar Plan, Modified Endowment Contract, other)		 Yes  No   Don't Know

Does the trust require any special administrative handling? * Yes  No   Don't Know

If yes, please explain.