Basic Policy Information

Carrier

Product Name

Product Type

Term Length

years

Product Details

Rate/Risk Class

Enter Other Rate/Risk Class

Face Amount ($)

Term Rider/Length ($)

Riders (Select all that apply)

Accidental Death BenefitWaiver of PremiumReturn of PremiumChild RiderConfirm availability before selecting

How many Child Rider Units?

Other riders (Please specify)

Premium Mode:

Premium Quoted ($)

Purpose of insurance (business, personal, income replacement, etc.)

If available, e-Deliver policy?

YesNoIf marked yes, a paper policy will not be issued

Billing type

Owner Information

Will insured own the policy?

Yes

No

Owner is a...

Please describe owner...

Owner is a trust

Trust Name

Trustee Name

Trustee email

Trustee mobile phone

Trust date

Trust Tax ID

Owner is a corporation

Ideally, the company officer is not the insured

Company Name

Company officer name

Company officer email

Company officer mobile phone

Company Tax ID

Company relationship to insured

Owner is a person

Owner Name

Owner email

Owner Relationship to Proposed Insured

Owner mobile

Owner SSN

Owner DOB

Owner Street Address

Owner City

Owner State

Owner Zip

Producer Information

Producer's First Name

MI

Producer's Last Name

Producer's Cell Phone Number

Producer's Email Address

Producer's MVP Contact

Select "Assign one to me" if you do not already have a contact

MVP Contact Name - Other

Broker / advisor SSN

SSN is required for advisors submitting their first application through the term-intake process and will be kept confidential under the AimcoR Privacy Policy practices

Company name

CRD no.

Broker-dealer affiliation

Is producer acting on behalf of a firm?

YesNo

Firm Name

Firm EIN

Proposed Insured's Information

Insured's First Name

MI

Insured's Last Name

Date of Birth

Date to Save Age

YesNo

Gender

Marital Status

Birth Country

Birth State

U.S. Status?

Visa Number

Green Card Date of Issue

Country of residence

State of residence

Client Social Security Number

Please enter if this is your first submission.

Driver's License or ID State

D/L or State ID no.

D/L or State ID expiry

Active-duty service member of U.S. Armed Forces (including National Guard/Reserves)?

Proposed Insured's Residential Address

Street address

Street address 2

City

State

Zip code

Country

Is mailing address the same?

Length of time at current address?

Proposed Insured's Mailing Address

Street address

Street address 2

City

State

Zip code

Country

Proposed Insured's Contact Information

Phone Number

Email

Contact proposed insured at the following email address (select all that apply)

PersonalWork

Proposed Insured Employment & Income Information

Is the applicant employed?:

Annual income

$

Please do not include commas or decimals
Only whole numbers

Est. assets

$

Est. liabilities

$

Net worth

$

(assets minus liabilities)

Proposed Insured Employment Details

Job title / position

Years at company

Employer’s name

Employer street address

Employer street address 2

Employer City

Employer State

Zip code

Employer Country

Proposed Insured Basic Medical Details

Height (ft)

Height (in)

Weight (lbs)

10+ lbs change in last year?

Weight Change Questions

Weight gain or loss?

GainLoss

Weight change amount

lbs

Reason for weight change?

Tobacco / vape usage?

Type of tobacco or vape

Date of last tobacco / vape use

Has the client (proposed insured) ever been treated for the following? (Please check all that apply)

CancerHeart diseaseStroke

Date of stroke diagnosis?

Date of heart disease diagnosis?

Date of cancer diagnosis?

Prudential

Tax Certification

Under penalties of perjury, the policyowner certifies that:

The policyowner is subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue CodeThe policyowner is NOT subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue Code

The policyowner is subject to FATCA reporting.

YesNo

I am a U.S. person (including a U.S. resident alien). If not a U.S. person (including U.S. resident alien), submit the applicable Form W-8.

YesNoA U.S. Person also includes U.S. Businesses and Trusts.

Upload Form W-8:

Agent Report

Is the proposed insured a prior client of yours?

YesNo

Other; please explain

Are there additional Producers?

YesNo

Producer Name

Producer Number

Split %

What is the source of funds used to pay premiums on this policy?

What is the policy number(s) for the source of the premiums? If more than one policy or contract, provide full details in the Remarks section.

Will any of the above policies cease to exist?

YesNo

What is the form of the proceeds for the above policy(ies)?

Accumulated dividendsLoansPartial surrender or withdrawal

Has the client been issued a Prudential/Pruco policy within the past 3 months?

YesNo

What is the policy number that you would like to use the requirements/declaration from?

Has the health, mental or physical condition of the proposed insured changed since the answers and statements were given in the above application?

YesNo

Is the Proposed Insured an active duty service member of the United States Armed Forces (including National Guard and Reserve)?

YesNo

Is the policyowner, or the person to whom this policy was sold, an active duty service member of the United States Armed Forces (including National Guard and Reserve)?

YesNo

Expected first year cost of this policy

Include Remarks or Special Instructions

Producer's Statement

To the best of my knowledge, a replacement is involved in this transaction.

YesNo

Did you see the proposed insured during the sales process?

YesNo

Do you intend to deliver the policy face to face?

YesNo

PLEASE READ:

I certify that:

- The solicitation or sale did NOT take place on a military base or other Department of Defense (DOD) installation;

- I have no knowledge of any factors which may have a negative effect on the proposed insured's insurability;

- I have given the Important Notice About Your Application for Insurance to the proposed insured;

- I provided the policyowner with the brochure "What every consumer should know about life insurance" and answered any questions they had about the purchase;

- If required by state regulation, I have read the Important Notice Regarding Replacement aloud to the applicant or the applicant did not wish the notice to be read aloud;

- If this is for the sale of an equity-indexed product: I have provided the owner(s) with the appropriate disclosures;

- I have no other information, other than as previously reported, that the proposed insured has existing life insurance or annuities or that indicates this coverage may replace or change any current insurance or annuity in any company

- All of the above statements are true and accurate.

HIV Consent

Disclose a positive test result to the physician I designate below:

Name

Address

City

State

Zip Code

Primary Beneficiaries

Primary Beneficiary is a...

Name

DOB

Relationship

Percent

%

Social Security Number

Phone

Trust Name

Trustee Name

Trustee Email

Trust Date

Trust Tax ID

Trustee Mobile Phone

Percent

%

Company Name

Company Officer Name

Company Tax ID

Company Officer Email

Company Officer Mobile Phone

Percent

%

Name

Contact

Percent

%

Additional beneficiary details (Tax ID, relationship, etc.)

Contingent Beneficiaries

Would you like to add any contingent beneficiaries?

Yes

No

Contingent beneficiary is a...

Name

DOB

Relationship

Percent

%

Social Security Number

Phone

Trust Name

Trustee Name

Trustee Email

Trust Date

Trust Tax ID

Trustee Mobile Phone

Percent

%

Company Name

Company Officer Name

Company Tax ID

Company Officer Email

Company Officer Mobile Phone

Percent

%

Name

Contact

Percent

%

Additional beneficiary details (Tax ID, relationship, etc.)

Does proposed insured have existing life insurance coverage?

YesNo

For existing coverage, please list Insurance Company(s), Death Benefit(s), Issued Year(s), and Policy Number(s)

Is the policy you are applying for replacing any existing coverage?

YesNo

Please indicate which policy or policies are being replaced and reason for replacement

Additional Information

Has the client ever been declined, rated or postponed for life or health insurance?

YesNo

Please explain

Did you meet with the client personally to complete this form?

YesNo

Was an illustration presented to the insured?

YesNo

If an investigative consumer report is prepared in connection with this application, would you like to be interviewed?

YesNo

This is the final page

Any additional comments, remarks, or instructions?

Authorization Disclaimer: By submitting this form to MVP Financial Services, you (writing agent) are attesting to the fact that you do want this insurance request submitted to the carrier on behalf of the applicant.

8 am to noon	Lunchtime	1 pm to 5pm
After 5 pm	Saturday	Saturday and Sunday

	Initial	Future
Current Income
CDs or Savings
Mutual Funds or brokerage account
Existing life insurance policy(ies) or annual contract(s)
1035 Exchange