State: Zip:
Name:
Phone (w):
Address 1:
City:
G.O. Name:
F
irst Name: Last Name:
DOB/Age:
Underwriting
Class:
(Required for California & Arkansas Clients)
AGENT INFORMATION
Effective tax rate:
Estimated pre-tax earnings rate of reserve account:
Address 2:
CA/AR Insurance License #
Agent Code:
Mobile:
Insured Information
Number of Premium Paying Years:
Minimum needed to maintain in reserve account:
Current amount held in the reserve account:
Name to appear on cover (prepared for):
Gender:
PERMANENT POLICY INFORMATION
Use PDA?
Annual OPP:
Amount of Reserve Cash to fund
Life Insurance:
Annual Premium Illustrated:
Bas
e Face Amount:
Dividend Option Term:
Alternative to
Cash on the Balance Sheet
Questionnaire
Term Policy Number if converting:
* Minimum required information in red
CLIENT PROVIDED INFORMATION
Click to Submit via
email.
TX
0.00%
**For rates in excess of 3.75% this concept should
not be used**
0.0%
Male
Yes
10
Bank Money Market
Bank CD
Bank Savings
Other
:
What do you like most about your current Reserve Account?
Where are your current reserve account assets invested?
CURRENT RESERVE ACCOUNT INFORMATION
Why do you hold the money in the Reserve Account?
How important is it for you to maintain the minimum balance in your Reserve Account in all years?
This material is to be completed with information and assumptions provided by the client. New York Life Insurance Company, its agents or employees may not
give legal, tax or accounting advice. Clients should consult their own professional advisors before implementing any planning strategies.
© 2016 New York Life Insurance Company. All rights reserved. SMRU 504347 (exp. 8.31.2022)
What do you like least about your current Reserve Account?