ILS Illustration Request Form This form will be required to submit illustration requests to the home office Agent Info: First Name Last Name Agent Email Client Info: First Name Last Name Male / Female MaleFemale Client Age / Date of Birth Health Rating Ultra-PreferredSelect PreferredNon-SmokerTobaccoTable Rating (Specify Below) Specifications: Product Type(s) Mass L100 Mass HECV Guardian L95 Guardian L95 Index Other (Specify in the Notes Below) Frequency the client would like to contribute AnnuallyMonthly Funding Scenario #1 (Annual contribution and to what age) Funding Scenario #2 (Annual contribution and to what age) Funding Scenario #3 (Annual Contribution and to what age) Target Death Benefit: Target MEC Limit: Additional Options: If a 1035 Exchange will be involved, please specify the amount: If you would like to see an income option, please select which scenario it will apply to: N/AFunding Scenario #1Funding Scenario #2Funding Scenario #3 If you would like to see an income option, please specify the year/age it should begin and the year/age it will end: If you would like to see additional reports, please select from the list below: Guaranteed Values IRR Report Other (Specify in the Notes below) If the requested scenarios are needed by a certain date, please specify: Notes: Submit