SECTION I: PRIMARY INSURED
11
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BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION I: PRIMARY INSURED
Name
姓名
Gender
性别
女 Female
男 Male
Height
身高
Weight
体重
Country Of Birth
出生国家或州
Are you a U.S. Citizen?
是否美国公民
Yes
No
Home Address
地址
Phone #
电话
Email address
电邮
SSN
社会安全号码
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SECTION II: OWNER FINANCIAL INFORMATION
22
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION II: OWNER
FINANCIAL INFORMATION
Annual Income
本人年收入
Net Worth
净值
Household Income
家庭年收入
Household Net Worth
家庭净值
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SECTION III: PRIMARY BENEFICIARIES
33
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION III-A:
PRIMARY BENEFICIARIES
Relationship to Insured
受益人关系
Name
姓名
Social Security #
社会安全号码
Date of Birth
生日
MM
/
DD
/
YYYY
Share %
百分比
SECTION III-B:
SECONDARY BENEFICIARIES
Relationship to Insured
受益人关系
Name
姓名
Social Security #
社会安全号码
Date of Birth
生日
MM
/
DD
/
YYYY
Share %
百分比
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SECTION IV: BANK INFORMATION (EFT)
44
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION IV:
BANK INFORMATION (EFT)
Bank Name
银行
Routing #
路由号码
Account #
支票账号
Bank Draft Date
扣款日期
MM
/
DD
/
YYYY
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SECTION V: PHYSICIAN INFORMATION
56
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION V:
PHYSICIAN INFORMATION
Doctor's Name
家庭医生名称
Address
地址
Phone #
电话
Date of Last Consult
最后一次看医生的时间
MM
/
DD
/
YYYY
Reason for Last Consult
路由号码
What's the outcome of the last consult?
检查结果
List any Medical Issues
医疗问题
List Medication Taken
正在服用的药物
Are you a smoker?
有抽烟吗？
Yes
No
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SECTION VI: FAMILY INFORMATION
67
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION VI:
FAMILY
INFORMATION
Birth Father's Age
父亲年齿
Alive or Deceased?
建在或过世
Deceased
Alive
If applicable, reason of death:
死因
Birth Mother's
Age
母亲年齿
Alive or Deceased?
建在或过世
Deceased
Alive
If applicable, reason of death:
死因
Does parent/owner have insurance coverage?
Yes
No
Company Name
Amount of coverage
Are the siblings equally insured?
Yes
No
no siblings
Sibling Name
Age
Company Name
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SECTION VII: CONFIRMATION
78
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION VII: CONFIRMATION
Referrer Name
介绍人姓名
Referrer Number
介绍人电话
Signature
Clear
Do you agree to have an agent to run an illustration based on the provided information above?
I agree to have an agent run an illustration.
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SECTION II: OWNER INFORMATION (Parent)
89
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
SECTION II: OWNER INFORMATION (Parent)
Name
姓名
Add more
Relationship to Insured
Gender
性别
女 Female
男 Male
Height
身高
Weight
体重
Country Of Birth
出生国家或州
Are you a U.S. Citizen?
是否美国公民
Yes
No
Home Address
Residential Address same as Insured
Residential Address
地址
Phone #
电话
Email address
电邮
SSN
社会安全号码
Please upload a copy of Driver's License.
请上传您的驾照副本
Delete all uploads
Choose files or drag here
Are you currently employed?
就业情况
Yes
No
Place of Work / Company Name
工作场所 公司名字
Job Title
职称
Work
Address
工作地址
Working Permit
工作许可证
Delete all uploads
Choose files or drag here
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100
%
BABY COLLEGE FUNDING PLAN PRE-QUALIFICATION FORM
Short text
Verification
SUBMIT FORM
Please wait...
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