Cover Sheet For All Correspondence ‐ Mail or Fax Date: ______________________________ Number of pages including cover sheet: ____________ Attention: _________________________________________________________________________________ Fax Information/Special Instructions: ____________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Person to contact for additional information: ____________________________________________________ Agent Name: _____________________________ Phone Number: ___________________________ Fax Number: ________________________________ Has the Paramed Exam been scheduled? Yes ____ No ____ Company Name: _______________________________________________ Do you want us to call in the Paramed Exam? Yes _____ APPLICATION COMPLETION TIPS ‐ SUBMIT A COMPLETE AND ACCURATE APPLICATION WITH SUPPLEMENTAL FORMS. ‐ Insured/Owner and all additional insured MUST sign. ‐ Use permanent BLACK INK. ‐ LEGIBLY print in English. ‐ NO white out. Any changes to written answers must be initialed by applicant/proposed insured. ‐ Address to include street, city, state and zip code (all numbers legible). ‐ BENEICIARY ‐ Provide given name of beneficiary and relationship. Fax: 888‐799‐8995 Overnight Applications to: Arizona Life & Annuity Brokers 1270 N. Broadway Rd #112 Tempe, AZ 85282