AMERICAN GENERAL COMPETITIVE TERM
Paperless Application Request

(* required fields)

*Customer's Name: *Officer's Name: Bank:  
*State where app will be signed: *Licensed agent name:
(Enter name of licensed agent or "same as above")
Location:  
*Officer/Agent E-Mail: Officer/Agent Phone: FAX:


Product Name: *Face Amount: * Rate class quoted:
(Please select from above drop down menu)
*Phone number for Customer Contact: Premium Mode: TABLE RATING:
(If table rated, please select table rating)
 
Day(s) of the week for contact:*
Any Week Day
 OR 
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
(check all that apply)

Best time of day for contact:*
Morning
Afternoon
Evening
(check all that apply)

Collateral Assignment desired? (check to indicate YES)

Any details about your customer that will aid in our interview with them?

Prior to submitting this form, please make sure all the fields with an "*" are completed.

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