Life Enrollment Form

Multi-Life, Inc.
*Marketers of: Group - Life - Health - Disability*

A Brokerage Firm Serving the Insurance Needs of Agents and Companies Throughout the Southeast

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Life Enrollment Form

One you have completed the information you will receive an application in the mail that you MUST sign and return in the envelope that will be provided.

Employee's Name:
Social Security # :
Phone#:
Address:
City:	State: Zip:
Annual Salary: $
Insurance In Force: $
Are you actively at work?	Yes	No
Insurance Type:	Allstate Term Life	ING UL Life

**Proposed Insured**
	Name: First MI Last	Birth Date			Birth State	Age as of Policy Effective Date	Sex (M or F)	Initial Face Amount
	Name: First MI Last	Mo.	Day	Year	Birth State	Age as of Policy Effective Date	Sex (M or F)	Initial Face Amount
Employee								$15,000 $25,000 $50,000 $75,000 $100,000
Spouse								$15,000 $25,000 $50,000 $75,000 $100,000
Dependent Child #1								$5,000 $10,000
Dependent Child #2
Dependent Child #3
Dependent Child #4

For more than **4 Dependents** Please Call 1-800-607-8833.

**Answer all Questions for Every Proposed Insured.**
	Employee	Spouse	D#1	D#2	D#3	D#4
1. Has the Proposed Insured used tobacco in any form in the last 24 months (2 years)?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No
2. Is the insurance now applied for intended to replace, in whole or in part, any insurance or annuities on the life of the Proposed Insured?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No
For Employees ages 66-70, Spouse, and Dependents Only 3. Has the Proposed Insured been hospitalized in any medical facility or nursing home, as either an in or out patient, within the past 90 days?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No

Beneficiary Information		Relationship
Employee Policy
Spouse Policy
Dependent Child #1
Dependent Child #2
Dependent Child #3
Dependent Child #4

**Proposed Insured**
Initial Semi-Monthly Premium
Initial Semi-Monthly Premium
Employee
Spouse
Dependents

A copy of the data above will be printed when you submit this form.

Please retain for your records.

For help or additional questions call 800-607-8833 between 8:00 AM and 5:00 PM, Monday through Friday.