WIN Pre Case Analysis Form

WEALTH INCREASE NETWORK, L.P.
CASE QUALIFICATION FORM

1. PERSONAL DATA
First Insured	Date of Birth Sex M F
Second Insured	Date of Birth Sex M F

2. LIFE INSURANCE POLICY INFORMATION
POLICY #1
Policy Issue Date	Contestability Period Yrs	Face Amount $
Cash/Account Value $	Policy Loan $	Interest Rate %
Premium Payment $ Annual? Semi Annual? Quarterly? Monthly?
Type of Policy? Term? Whole Life? Universal Life? Other?
Type of Insurance (Key Man, Second to Die etc.)
Insured? First Insured? Second Insured? Both?

POLICY #2
Policy Issue Date	Contestability Period Yrs	Face Amount $
Cash/Account Value $	Policy Loan $	Interest Rate %
Premium Payment $ Annual? Semi Annual? Quarterly? Monthly?
Type of Policy? Term? Whole Life? Universal Life? Other?
Type of Insurance (Key Man, Second to Die etc.)
Insured? First Insured? Second Insured? Both?

POLICY #3
Policy Issue Date	Contestability Period Yrs	Face Amount $
Cash/Account Value $	Policy Loan $	Interest Rate %
Premium Payment $ Annual? Semi Annual? Quarterly? Monthly?
Type of Policy? Term? Whole Life? Universal Life? Other?
Type of Insurance (Key Man, Second to Die etc.)
Insured? First Insured? Second Insured? Both?

3. MEDICAL INFORMATION SUMMARY
FIRST INSURED: Present Table Rating
Medical Condition:

SECOND INSURED: Present Table Rating
Medical Condition:

SUBMITTED BY:
Name: Company:
Tel: Fax: email:
Remarks

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