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Request for Interview

**Make sure to schedule a time for your client to be called**

Request for Interview Form

Insurance Company and Product Information: (Please upload a full illustration for Permanent Quotes)

Current Carrier/Products we are unable to do App-Solution with: 1) ALL Banner Life Products (App Assist or Horizon eApp only) 2 ALL Protective Applications 3) Assurity Income Protection Product 4) John Hancock (Outside NY)
Product Type (Annuities not allowed):(Required)
Product Type(Required)
Put $0 for Long-Term Care or Disability applications
**If Yes, please put the name of the rider(s) in the note section below

Client Information:

Client Name:(Required)
MM slash DD slash YYYY
*Includes Cigarettes, Cigars, Vapes, and Patches. If none put none.
*If none put none
*If none put none

Once we receive the interview request form and a date is scheduled. A Specific Solutions representative will contact your client two business days before to confirm your client’s scheduled time for the phone interview.

Agent Acknowledge
By submitting this form, you agree to the terms for App‐Solution. You also acknowledge that the App Solution process has been explained to your client and that you agree your client wants to be contacted by a Specific Solutions Representative and complete the information gathering part of the application process. You also agree your client will share information as requested during the phone interview and that all information is deemed accurate to the best of their knowledge.