Life Insurance Onboarding Form
Please complete the below fields to obtain a proposal for Life Insurance.
Monday.com Title
Policy Type
Life Insurance - What You Need To Know
First Name
*
Last Name
*
Full Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email To Send Proposal To
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
The Purpose for this Life Insurance policy is...
*
Desired Effective Date of Policy
*
-
Month
-
Day
Year
Date
Are You Married?
*
Yes
No
Spouse's First Name
*
Spouse's Last Name
*
Spouse's Full Name
Spouse's Birthday
*
-
Month
-
Day
Year
Date
Do You Have Any Children?
*
Yes
No
Children's Name(s) & Ages
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Height
*
Ex: 5ft 8in
Weight
*
Ex: 175 lbs.
Do You Smoke?
*
No
Yes
In The Past Year Have You Lost More Than 20lbs
*
No
Yes
How Often Do You Use Tobacco
*
Please Select
Never Use Tobacco
Past User - Quit Over 24 Months Ago
Current User or Quit Within The Past 24 Months
I am interested in the same day issue life insurance product and would like to answer the 5 brief medical underwriting questions that are required.
*
Yes
No
In the past 10 years, have you used any controlled substance (other than marijuana) such as cocaine, heroin, opioids, narcotics, barbiturates, amphetamines, sedatives or hallucinogens without a medical prescription?
*
No
Yes
Have you ever been convicted of or pled guilty or no contest to any felony or are you currently under indictment, awaiting trial or sentencing, or on probation or parole?
*
No
Yes
In the past 5 years, have you ever had or been advised by a member of the medical profession to have a kidney, liver, heart or other internal organ transplant?
*
No
Yes
Have you ever been diagnosed with, treated, tested positive for, or been given medical advice by a member of the medical profession for:
*
Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?
Any disease or disorder of the heart including, but not limited to: coronary artery disease, heart attack, coronary arterybypass, angioplasty or stents, heart valve disorder or surgery?
Any disease or disorder of the brain or nervous system including, but not limited to: multiple sclerosis, Parkinson’sdisease, stroke or transient ischemic attack (TIA), aneurysm, muscular dystrophy, ALS (Lou Gehrig’s disease), or paralysis?
Any cancer (other than non‐melanoma skin cancer) including, but not limited to: malignant tumors, lymphoma,Hodgkin’s disease, leukemia, or melanoma?
Diabetes, kidney disease or disorder, hepatitis B or C, fibrosis or cirrhosis of the liver?
Any disease requiring the use of oxygen including, but not limited to: emphysema or chronic obstructive pulmonarydisease (COPD)?
Bi‐polar disorder, schizophrenia, psychosis, suicide attempt or post‐traumatic stress disorder (PTSD)?
None Of These Apply
In the past 2 years, have you been hospitalized for any reason (other than normal pregnancy and child delivery)?
*
No
Yes
Desired Death Benefit Amount
*
Please Select
$100,000
$200,000
$300,000
$400,000
$500,000
Desired Death Benefit Amount
*
Desired Policy Term Length
*
Please Select
10 Years
15 Years
20 Years
30 Years
40 Years
Whole Life
Are You A Current MM Insurance Customer?
*
No
Yes
Customer Type
Potential Delay
**Given your answer(s) to one or more of the above questions, your application may take longer to process. Please allow us extra time to provide your quote**
Submit
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