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Select 79 Proposal Request Form - Economic Concepts Inc.

Date Requested
Producer's Name
Phone No. Email Address
Unless noted otherwise, the proposal will be sent to the producer noted above.
Insurance Policy Info
 Life of the Southwest/National Life Pacific Life
Projected Interest Rate Year 6+
State of Policy Issue
State :
If CA, license #: :
Primary Objective (choose one)
 Reduce Taxable Income Today Maximize Tax-Free Retirement Income Provide Death Benefits
Company Information
Name of Business
Less than 10 Employees?  Yes No
Tax Related Info
C Corporation  Yes No
Fiscal Year End
Tax Bracket %
Total number of Employees
Group Term Info
Is there an existing group term
 Yes No
If yes, no. of employees
participating in plan?
If no, would you like ECI
to provide a quote?
 Yes No
Group Term Quote (complete if would like ECI to provide a quote for group term insurance)
Business Address
Company Census (complete data below or attach full census with requested information)
Participant's Name %of Ownership Key Person (Y/N) DOB or Age Gender & Und. Class Annual Compensation Contribution Desired

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