LIFE Foundation

Life and Health Insurance Foundation for Education

realLIFEstories® 2010 Client Service Awards Application Form
Learn more about realLIFEstories here
You can also download a PDF version here

Required fields are indicated by an asterisk (*)

ABOUT YOU:

First Name: *
Last Name: *
Title:
Agency Name: *
Address: *
Address2:
City: *
State: *
Zip: *
Telephone: *
Cell: *
Fax:
Email: *
Primary Company:
State(s) in which licensed: *
How many years have you been in insurance sales? *

Professional Designation(s):
CASL CLU CFP CPCU	CLTC ChFC FSS FLMI	HIA LUTCF REBC RHU

Other

Are you a member of a professional insurance agent or financial planning association(s)?
Yes No

If yes:
AALU FPA GAMA Intl	IIABA Intl. Forum MDRT NAHU	NAIFA PIA SFSP

Other

1. What category of insurance is your story?
	Individual Life Insurance Which of the following does your story involve?
	Death Benefits	Living Needs Benefits	Business Continuation
	(Top 2 stories will be chosen from this category)
	Individual Disability, Long-Term Care or Health Insurance Which of the following does your story involve?
	Disability	Long-Term Care	Health
	(1 story will be chosed from this category)
	Workplace Benefits Which of the following does your story involve?
	Life	Disability	Long-Term Care
	Type of Coverage
	Employer Paid	Employee Paid
	(1 story will be chosed from this category)

2. To protect the client's privacy, please provide only first name, city and state.
Client's First Name
Client's City
Client's State

3. Please indicate your client's race/ethnicity (optional):
	African American/Black
	Asian American
	Asian, including Indian Subcontinent
	Hispanic/Latino/Mexican American
	Native American/Alaska Native
	Native Hawaiian/Pacific Islander
	White/Caucasian
	Other (please list below)

4. Year event took place
(only events that benefited clients from Jan 1st, 2000, or later are eligible)

5. Which of the following financial products did your client have?
	Life
	Health
	Disability
	Long-term care
	Annuities
	Other (please list below)

6. From which company(ies) was the policy(ies) that benefited your client purchased?

7. How long was the policy(ies) that benefited your client in effect?
years

8. Briefly describe how your client used the money from his/her policy(ies):

9. Has this story ever appeared in a national consumer publication?
Yes No

10. How did you first learn about this year's realLIFEstories Client Service Award program?
	Agency
	Company
	Email
	Trade Publications
	Local or state associations
	Direct mail
	Other (please list below)

Enter verefication code:
Essay: (In the form below, please write an essay of no more than 600 words describing your client's realLIFEstory. Entries will be judged primarily on the compelling nature of the stories and how well they demonstrate the role and value of life, health, disability, or long-term care insurance. Exceptional service on the part of the agent will also be an important criterion. If your story is chosen to be featured in Newsweek, it will be professionally rewritten prior to publication.

	I certify that all information submitted is accurate to the best of my knowledge.