Complete and verifiable information is required in order to qualify for this Magazine Subscription.

First Name: Last Name:   Job Title:   Company Name:   Business Email: Phone: Fax:

Division/Mail Stop: Street Address: City: State/Province: Select for USA, Canada, or Mexico Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Marshall Islands Micronesia (Federated States of) Palau Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands Northern Mariana Islands Armed Forces Americas AA Armed Forces Middle East, Europe, Canada AE Armed Forces Pacific AP Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Chihuahua Distrito Federal Durango Guanajuato Guerrero Hidalgo Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Queretaro Quintana Roo San Luis Potosi Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz Yucatan Zacatecas Other Postal/ZIP code: Country: Select Country UNITED STATES CANADA INDIA UNITED KINGDOM == AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN AZORES BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BR VIRGIN ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANARY ISLANDS CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REP CHAD CHANNEL ISLANDS CHILE CHINA, PEO REPBL CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ELAND ISLANDS EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUINEA FRENCH POLYNESIA GABON, REPUBLIC OF GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA BIASSAU GUINEA,REPUBLIC OF GUYANA HAITI HONDURAS HONG KONG HUNGARY ICELAND INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KOREA,DEMOCRATIC REPUBLIC OF KOREA,REPUBLIC OF KOSOVO KUWAIT KYRGZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MADEIRA MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU ISLANDS NEPAL NETHERLANDS ANTILLES NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL QATAR REPUBLIC OF KIRIBATI REUNION ROMANIA RUSSIAN FED RWANDA SAINT PIERRE AND MIQUELON SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOCIETY ISLANDS SOLOMON ISLANDS SOMALIA,REPUBLIC SOUTH AFRICA SPAIN SRI LANKA ST KITTS ST LUCIA ST VINCENT SUDAN SURINAM SWAZILAND SWEDEN SWITZERLAND SYRIA TAHITI TAIWAN TAJIKISTAN TANZANIA THAILAND TIMOR-LESTE TOGO TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNION OF MYANMAR UNITED ARAB EMIRATE UNITED KINGDOM,ENGLAND UNITED KINGDOM,NO.IRELAND UNITED KINGDOM,SCOTLAND UNITED KINGDOM,WALES URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM, RPBLC OF VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA WESTERN SAMOA YEMEN ZAMBIA ZANZIBAR ZIMBABWE OTHER

Yes, please auto-fill my contact information for other qualification forms.

Your offer confirmation will be sent to your business email address entered above.

Which of the following is closest to your job function?

Select Job Function Administration Finance Marketing/Sales Manufacturing/Operations Engineering/Technology Administration Finance Marketing/Sales Manufacturing/Operations Engineering/Technology Administration Finance Marketing/Sales Manufacturing/Operations Engineering/Technology Administration Finance Marketing/Sales Manufacturing/Operations Engineering/Technology Other Please Specify for Other:

What is the approximate number of employees in your company?

Select Number of Employees 50,000+ 20,000 - 49,999 10,000 - 19,999 5,000 - 9,999 2,500 - 4,999 1,000 - 2,499 500 - 999 250 - 499 100 - 249 50 - 99 25 - 49 10 - 24 5 - 9 1 - 4

I do not wish to receive relevant third party offers and/or special promotions.

---

1.

Do you wish to receive a FREE subscription to Life Insurance Selling?

Yes     No

2.

In which format would you prefer to receive your subscription?

Digital     Print     No Preference

3.

Which is your primary profession?

Select primary profession Producer with Life/Health focus Producer with Financial Planning focus Life General Agent or Manager Insurance Company Personnel Other Please specify for Other:

4.

Are you a licensed Life/Health Agent?

Yes     No

5.

Last year, what was the amount of your paid personal life production (face amount)?

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

6.

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 for Other:

7.

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

	Estate Planning	Senior Market
	Employee Benefits	Boomer Market
	Business Insurance	Other
		Please specify for Other:

8.

Which professional designations/licenses do you hold? (select all that apply)

	CLU	CEBS
	ChFC	LTCP
	CFP	Series 6
	RHU	Series 7
	CLTC	Other
		Please specify for Other:

9.

In lieu of a signature, Summit Business Media LLC requires a personal identifying question. What day of the month were you born on?

Select day of month 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

---

Would you like to receive EMAIL notices of other print or online publications, and other relevant offers from TradePub.com?

Yes     No

Sign up for special offer alerts from select partners featuring the latest products and services you are interested in.

Yes     No