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Applicant Information: ID# 998079
Name: XXXX XXXXXXXX Gender: XXXXXXXX Birth date: 12/14/48
Address: XXXXX XXXXXXXXXX XXXX City: Farmington State: New Mexico Zip: XXXXX
Work Phone: XXX-XXX-XXXX Home Phone: XXX-XXX-XXXX Best Time To Call: 8-20 a.m.
E-mail Address: xxxxxx@earthlink.net

Quote Information:
Are you requesting for yourself? Yes

Insurance Request Information:	Health Information:
Amount of insurance wanted: $1,000,000 - $2,000,000	Do you use Tobacco: No
Type of insurance wanted: Whole Life	What type of tobacco products: N/A
Primary purpose(s): Income to family after death	Height: 5' 7"
What term would you like: 99	Weight: 178
Amount of Insurance now in force: $750,000.00	Health Problems: None
Premium you are paying per year: $7500.00	Medications: None
When is the last time you applied: 5+ years ago	Names/doses: N/A
To which companies: AXA Advisors	Family member - Heart Disease/Cancer: None
What Was The Outcome: Accepted	Describe: N/A