Term Life Insurance Fact Finder

Please complete the following questions to support your life insurance application process. The information provided is not binding, you will have the ability to review all finalized coverage options, and costs once the formal application and medical exams are completed.

POLICY CONFIGURATION

Applicant Full Name (First, Middle, Last): *

Application State Of Coverage: *

Applicant Email Address For E-Signatures: *

Select Reason For Insurance: *

Select Face Amount Of Coverage: *

Select Duration Of Term Coverage: *

Optional Riders/Additional Benefits: *

Waiver Of Premium Rider - waives insurance premium payments if the policyholder becomes critically ill or physically impaired.
Terminal Illness Rider - allows you to access your policy's death benefit before you die if you're diagnosed with a qualifying serious illness — typically a terminal one.
None

Ownership Type Of The Life Insurance Policy (Buyer Of This Policy)?: *

Is The Primary Insured Person Also The Owner (Buyer Of This Policy)?: *

PRIMARY INSURED BASIC INFORMATION

Primary Insured Full Name (First, Middle, Last): *

Primary Insured Date Of Birth: *

Primary insured SS#:

The (If #

Primary Insured Gender: *

Female
Male

Is Primary Insured A US Citizen or Permanent Resident Card Holder?: *

Primary Insured Country Of Birth: *

Primary Insured State/Province Of Birth: *

Primary Insured Address: *

Primary Insured Cell Phone Number: *

Primary Insured Email Address (For E-Signature): *

Primary Insured Drivers License # & State: *

Primary Insured Personal Income (Annual, Insured Only, Not Household) *estimated is OK, this is for affordability testing*: *

Primary Insured Net Worth (Insured Only, Not Household) *estimated is OK, this is for affordability testing*: *

Household Income (Annual) *estimated is OK, this is for affordability testing*: *

Primary Insured Monthly Liabilties *

Please Provide the Primary Insured Basic Health Information (Only Answer What Is Relevant to You):

Height

Weight

Any Health Conditions and Year of Onset (Diabetes Type 1 or 2, Cancer, Stroke, Kidney Issues etc.):

A1C Level (If Diabetic):

List of Medications Taking (Name, Dosage, How Often, How Many Years):

BENEFICIARY INFORMATION

Beneficiary Full Name (First, Middle, Last) *

Beneficiary Date Of Birth *

Beneficiary SS#:

Beneficiary Phone Number

Beneficiary Email

Primary Beneficiary Relationship To Insured:

Primary Beneficiary Address: *

Beneficiary Allocation Percentage

If listing multiple beneficiaries, please indicate the percentage of the death benefit each beneficiary should receive. The total must equal 100%.

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service@monteleoneins.com | 631-544-4000