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What is the approximate number of employees in your company? (select only one)

Select Number of Employees Less than 50 50-99 100-499 500-999 1,000-4,999 5,000-9,999 Greater than 10,000

2.	Which professional designations do you hold? (select all that apply)

CLU	CLTC
ChFC	CEBS
CFP	CSA
RHU	LTCP
	None

3.	Which of the below is your primary profession? (select only one)

Producer with Financial Planning focus	Life General Agent or Manager
Producer with Life/Health focus	Insurance Company Personnel
Producer with Property/Casualty focus	Other (please specify)

4.	Do you sell: (select all that apply)

Universal Life	Mutual Funds, Bonds or other Kinds of Securities
Term Insurance	Fixed Annuities
Disability Insurance	Variable Annuities
Individual Health	Variable Life or Variable Universal Life
Group Health	Payroll Deduction or Work-Site Mktg. Prods.
Long-Term Care	Other (please specify)

5.	Do you work in the following markets? (select all that apply)

Estate Planning	Senior Market
Employee Benefits	Other (please specify)
Business Insurance

6.	Last year, what was the amount of your paid personal life production (face amount)? (select only one)

10 Million or more	$2 - $2.9 Million
$5 - $9.9 Million	$1 - $1.9 Million
$4 - $4.9 Million	$500,000 - $999,999
$3 - $3.9 Million	$Less than $500,000

7.	In lieu of a signature, we require a personal identifying question. What is the day of the month you were born?

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