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    MVP's Life Insurance Intake Form

Click here to access PDF intake form



Basic policy information






years
Check carrier guidelines if unsure of
eligible ages for selected term length


Click the "Next Page" button below to get started with your application


Primary agent information







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


SSN will be kept confidential under the AimcoR Privacy Policy practices
Agent's address 















Agent #2 information




SSN will be kept confidential under the AimcoR Privacy Policy practices




Agent #3 information




SSN will be kept confidential under the AimcoR Privacy Policy practices




Agent #4 information




SSN will be kept confidential under the AimcoR Privacy Policy practices




Business case information



$

 $

 $

Product details





Confirm availability before selecting
Term Riders

$
Confirm availability before selecting

$
Confirm availability before selecting

$
Confirm availability before selecting
Leave value at 0 if not applicable for specified term length

Confirm availability before selecting








If marked yes, a paper policy will not be issued



Owner information









Ideally, the company officer is not the insured                                                                                                                  


















Proposed insured's information























Proposed insured's residential address 








Proposed insured's mailing address 








Proposed insured's contact information





Proposed insured's income information

 $
Please do not include commas or decimals
Only whole numbers

 $
Please do not include commas or decimals
Only whole numbers

 $
(earned plus unearned)

 $

 $

 $
(assets minus liabilities)

 $

Proposed insured's employment details











Proposed insured's basic medical details




Weight Change Questions


lbs


E.g. cigarettes, cigars, vaping, chew, patch, gum







Primary beneficiary information


%
Percentages for all primary beneficiaries must sum to 100%






















Primary Beneficiary's Mailing Address 





If you want to add additional primary beneficiaries, click "Add another primary beneficiary" below this section

Please ensure that allocated percentages of all primary beneficiaries sum to 100%


Contingent Beneficiary


%
Percentages for all contingent beneficiaries must sum to 100%



















Contingent Beneficiary's Mailing Address 








If you want to add additional contingent beneficiaries, click "Add another contingent beneficiary" below this section

Please ensure that allocated percentages of all contingent beneficiaries sum to 100%


The below existing insurance/replacement questions must be asked of the proposed insured



Existing coverage policy information



$


To add more than one existing policy, click or tap "Add another existing policy" below this section



Proposed insured additional questions



$
Include wages, salaries, investment returns, retirement payouts, and welfare payments












Temporary Insurance or Conditional Coverage

If Temporary Insurance (TIAA) or Conditional Coverage is available, it will be determined by most carriers at time of phone interview
Temporary coverage cannot begin if you answer 'Yes' to any of the following questions:










Bank Information



Do not collect any money; agent is NOT allowed to collect any premium from applicant.

Additional information

Form collaboration information

Prudential - additional questions
Tax Certification



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

Agent Report












years



Confirm availability before selecting

Confirm availability before selecting







Producer's Statement



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 a variable product: I have provided current copies of the Privacy Notice and the ID Verification Notice to all owner(s) and legal representative(s); and I have offered the client a choice of a paper initial summary prospectus, or an electronic initial summary prospectus and provided the client with their choice

- If this is for the sale of an equity-indexed product: I have provided the owner(s) with the appropriate disclosures and marketing brochures, which highlight key features of the product;

- If this is a replacement: I have discussed the advantages and disadvantages of the replacement with the client and determined that the transaction is appropriate and I have completed the state-required replacement form(s);

- 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

- If I become aware of a change in the health or habits of the proposed insured occurring after the date of the application but before policy delivery, I promise to inform the Company of the change and agree to withhold policy delivery until instructed by the company;

- CA: The CA Disclosure Statement was provided to the policyowner in accordance with CA Insurance Code section 789.8;

- NY: I have fully discussed and explained the life insurance features and charges including restrictions to the applicant. I represent that: (a) this life insurance is suitable and in the best interest of the applicant in accordance with New York Insurance Regulation 187, (b) at or before the time of recommendation, I provided to the applicant all disclosures required under New York insurance regulations, including disclosing, in a reasonable summary format, all relevant suitability considerations and product information, both favorable and unfavorable, that provided the basis for my recommendation, and (c) I have a reasonable basis to believe that the applicant has the financial ability to meet the financial commitments of the policy.

- PA: The Disclosure Statement as required by the Commonwealth of Pennsylvania Insurance Department was delivered to the policyowner;

- VT: If the policy applied for is a charitable gift, I have provided the Charitable Life Gifts Disclosure form to the proposed insured;

- All of the above statements are true and accurate.

HIV Consent
 Physician Information - HIV Disclosure





Pacific Life - agent attestation

By clicking the I AGREE/SUBMIT button below, I state the following:


• I am duly licensed and appointed (if appointment is required) life insurance Producer in the state in which the applicant was solicited and in the state in which the policy, if one is issue, will be delivered.


• The product and amount of insurance identified is suitable in view of the owner's insurance needs and financial objectives.


• The information provided is complete, accurate, and correctly recorded.



• I authorize the Pacific Life Fulfillment Center's representative to obtain such administrative information as may be necessary to complete any life insurance application resulting from this lead submission, provided however, that any item of information or question from owner or Proposed Insured requiring the act or advice of a licensed life insurance Producer will be referred to me for action before the application can be completed.


• If applicable, I have explained that disbursement options such as loans, withdrawals or surrenders are not available through PL Express App and have advised the applicant they should apply outside of this process if they wish to pursue.



• If applicable, required forms have been provided.



• I have obtained sufficient information about the client to mitigate risks associated with money laundering, terrorist activity/funding, and to avoid doing business with a sanctioned individual or resident of a sanctioned country.

• I acknowledge that clicking the I AGREE/SUBMIT button below constitutes my signature on the form and has the same effect as if I personally signed the form.


• I certify and attest that: (a) Pacific Life's Consent to Electronic Delivery & Use of Automated Technology was presented to the Proposed Insured; (b) the Proposed Insured expressly, affirmatively, and voluntarily consented to the use of Electronic Delivery and Automated Technology by Pacific Life and its third-party vendors.


In addition to the authorizations referenced in the preceding paragraphs, by clicking the I Agree/Submit button below will, this will constitute my legally binding signature on the completed application and on all supporting documentation for the client's) referenced in the quick request associated with this attestation.


I hereby agree to the provisions in this attestation and affix my signature to the attestation and those documents referenced therein by signing below.

Legal & General (Banner) - agent attestation

We will rely on information provided by you. The answers to the questions you ask and collect from your client will be the basis for us to issue a life insurance policy. The answers provided to us will be made a part of the policy. Every answer you provide to us must be truthful, complete and accurate to the best of your knowledge. As an advisor, your responsibilities include, but are not limited to:

  • Ensuring your client does not require a translator.
  • Asking all questions exactly as presented, including scenarios where gender specific conditions must be asked to all clients.
  • Making us aware of any information that would adversely affect your client's eligibility, acceptability, or insurability.
  • Asking your client, the appropriate questions to ensure that the product, with the length and amount of coverage being applied for, is in the best interest of, and suitable for, your client.
  • Ensuring you are a licensed life insurance agent in the state where your client lives. If you are not currently appointed, you will get appointed before the policy is finalized.
  • Providing complete and accurate information in a timely manner, including all required forms (including any required notices)

By clicking the blue button below, you agree that:

You will work with your client to ensure that accurate and honest information is provided. You understand that if the wrong information is received, your client could miss out on coverage benefits.

You authorize Legal & General America to obtain any necessary administrative information order to complete this life insurance application. You understand that any information needed from your client requiring action and/or advice from a licensed life insurance agent will be referred to you for before the application can be completed.

Symetra drop ticket acknowledgement & authorization

Final notes -- PLEASE READ
If, for some reason, you cannot correct any form errors when you try to submit, please click "Save my progress and resume later" so MVP can help resolve the errors without losing your progress.
Authorization: By submitting this form to MVP Financial Services, you are attesting to the fact that you do want this insurance request submitted to the carrier on behalf of the proposed insured.
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