Business Continuity

Type *

Buy-Sell
Key Person

Entity Name *

Telephone *

Email *

State Of Domicile

Type Of Entity

Corporate Tax Bracket

Type Of Arrangement

Cross Purchase
Entity Redemption
Partnership

Valuation Amount

Valuation Method

1-Appraisal
2-Book Value Plus Multiple
3-Capitalization Of Earnings
4-Combination of 2 & 3

Owner / Shareholder Information:

Owner 1

Owner 1 Date Of Birth//

Owner 1 Sex

Male
Female

Owner 1 Tobacco

Yes
No

Owner 1 Underwriting Class

Owner 1 State Of Residence

Owner 1 Ownership %

Owner 2

Owner 2 Date Of Birth//

Owner 2 Sex

Male
Female

Owner 2 Tobacco

Yes
No

Owner 2 Underwriting Class

Owner 2 State Of Residence

Owner 2 Ownership %

Owner 3

Owner 3 Date Of Birth//

Owner 3 Sex

Male
Female

Owner 3 Tobacco

Yes
No

Owner 3 Underwriting Class

Owner 3 State Of Residence

Owner 3 Ownership %

Business Continuity

Fixed Annuities

Disability Income

Long Term Care Insurance

Life Insurance

Carriers we represent as general agents:

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Owner / Shareholder Information: