MPI™ Application

Proposed Insured Personal Information
Date MPI Plan Application Submitted
MM slash DD slash YYYY
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Company – Hidden

Used for dup check for data transferred to IS.
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Admin Name
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Admin Email
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Producer Name
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Producer Email
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Producer Number
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Primary Phone*
Current Age*
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
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Social Security Number
Gender at Birth*
- Male
- Female
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Gender at Birth = Male
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Gender at Birth = Female
US Citizen?*
- Yes
- No
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US Citizen = Yes
Hidden
US Citizen = No
Marital Status*
State of Birth (Country if not U.S.)*
Drivers License #*
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Driver's License #
Drivers License State*
State
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Must fill out FNFT_Yes

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Foreign National
1) Are you a Permanent Resident (holder of a Permanent Resident Card)?*
1) Are you a Permanent Resident (holder of a Permanent Resident Card)?*
- Yes
- No
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FNFT_Permanent Resident = Yes
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FNFT_Permanent Resident = No
If "Yes," please list your Permanent Resident Card Number:*
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If "Yes," please list your Permanent Resident Card Number:
If "No," please list the type of visa you hold:*
How long have you lived in the United States?*
2) Full name as stated on the Permanent Resident Card or Visa:*
3) Date of issue on your Permanent Resident Card or Visa:*
MM slash DD slash YYYY
4) Date of expiration on your Permanent Resident Card:*
MM slash DD slash YYYY
5) Do you own a home in the United States?*
5) Do you own a home in the United States?*
- Yes
- No
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FNFT_Own_US_Home = Yes
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FNFT_Own_US_Home = No
If "Yes," please provide the address:*
Street Address Address Line 2 City State ZIP Code
6) Do you own a home in a foreign country?*
6) Do you own a home in a foreign country?*
- Yes
- No
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FNFT_Foreign_Home = Yes
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FNFT_Foreign_Home = No
If "Yes," please provide the address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
7) If married, does your family live with you in the United States?*
7) If married, does your family live with you in the United States?*
- Yes
- No
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Married_Living_With_Family = Yes
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Married_Living_With_Family = No

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Financial Info
Employer*
Occupation/Duties*
Annual Income ($)*
Contribution Frequency & Method?*
- Monthly Bank Draft
- Annual Direct Bill
- Semi-Annual Direct Bill
- Quarterly Direct Bill
Contribution amount ($)*
Do you have an additional lump sum amount to contribute to accelerate your MPI™ plan?*
- Yes
- No
Total Lump Sum Amount*
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Contribution Frequency = Monthly
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Contribution Frequency = Annual
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Contribution Frequency = Semi-Annual
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Contribution Frequency = Quarterly
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Premium Payment Method = Direct Bill
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Premium Payment Method = Bank Draft
Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you?*
Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you?*
- Yes
- No
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Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you = Yes
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Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you = No
If Yes, please explain and provide the filing and discharge dates*

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Policy Owner Information
Is the Policy Owner a different person than the Proposed Insured?*
- Yes
- No
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PO different than PI = Yes
Hidden
PO different than PI = No
Policy Owner Type*
- Individual
- Employer
- Trust
- Other
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Policy Owner Type = Individual
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Policy Owner Type = Employer
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Policy Owner Type = Trust
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Policy Owner Type = Other
If "Other" specify:*
Policy Owner Full Name*
Policy Owner Relationship to Proposed Insured*
Policy Owner SSN/EIN*
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Policy Owner SSN/EIN*
Policy Owner Full Address*
Policy Owner Date of Birth/Date of Trust/Date of Organization*
MM slash DD slash YYYY
Policy Owner Primary Phone*
Policy Owner Email*

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Primary Beneficiary Information
If more space is needed, use the comments section below
Primary Beneficiary Full Name*
% of Proceeds (%)*
Date of Birth*
MM slash DD slash YYYY
Relationship to Proposed Insured*
Contingent Beneficiary Information
If more space is needed, use the comments section below
Contingent Beneficiary Full Name
% of Proceeds (%)
Date of Birth
MM slash DD slash YYYY
Relationship to Proposed Insured
Comments
Beneficiary Comments

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Foreign Travel
1) Are you employed in the United States?*
1) Are you employed in the United States?*
- Yes
- No
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Employed in the United States = Yes
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Employed in the United States = No
If "Yes," please provide the name and address of your employer and describe the duties you perform:*
If "No," please provide sources(s) of income while in the United States:*
2) Do you plan to travel outside of the United States in the next two years?*
2) Do you plan to travel outside of the United States in the next two years?*
- Yes
- No
Where do you plan to travel?*
What is the purpose of travel? (Select all that apply)*
- Business
- Pleasure
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FNFT_Purpose_to_travel = Business
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FNFT_Purpose_to_travel = Pleasure
How often?*
Average period of time for each trip:*
What was the date of your last trip?*
MM slash DD slash YYYY

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Health Info
Height (ft)*
Height (in)*
Weight (lbs)*
How many personal physicians have you seen in the relevant past, including your most recent visit?*
Physician #1 Info
Name, Address and Telephone Number of Personal Physician*
Date Physician Last Seen*
State Reasons, Findings and Treatment*
Physician #2 Info
Name, Address and Telephone Number of Personal Physician*
Date Physician Last Seen*
State Reasons, Findings and Treatment*
Physician #3 Info
Name, Address and Telephone Number of Personal Physician*
Date Physician Last Seen*
State Reasons, Findings and Treatment*
Physician #4 Info
Name, Address and Telephone Number of Personal Physician*
Date Physician Last Seen*
State Reasons, Findings and Treatment*

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Family History
Do you have a deceased parent(s) and/or siblings?*
Do you have a deceased parent(s) and/or siblings?*
- Yes
- No
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Do you have a deceased parent(s) and/or siblings = Yes
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Do you have a deceased parent(s) and/or siblings = No
Select the family members that have deceased?*
- Father
- Mother
- 1 Sibling
- 2 Siblings
- 3 Siblings
Father's Age of Death*
Father's Cause of Death*
Mother's Age of Death*
Mother's Cause of Death*
Sibling 1 Age of Death*
Sibling 1 Cause of Death*
Sibling 2 Age of Death*
Sibling 2 Cause of Death*
Sibling 3 Age of Death*
Sibling 3 Cause of Death*

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Drug/Alcohol Usage
In the past 10 years, have you:
1) used alcohol to a degree that required treatment, or been advised to limit, or discontinue its use by a member of the medical profession?*
1) used alcohol to a degree that required treatment, or been advised to limit, or discontinue its use by a member of the medical profession?*
- Yes
- No
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used alcohol to a degree that required treatment, or been advised to limit, or discontinue its use by a member of the medical profession = Yes
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used alcohol to a degree that required treatment, or been advised to limit, or discontinue its use by a member of the medical profession = No
2) used unlawful drugs in any form (including cocaine, marijuana, methamphetamines, and hallucinogens), or used prescription drugs other than as prescribed (including sedatives, tranquilizers, or narcotics) in any form?*
2) used unlawful drugs in any form (including cocaine, marijuana, methamphetamines, and hallucinogens), or used prescription drugs other than as prescribed (including sedatives, tranquilizers, or narcotics) in any form?*
- Yes
- No
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used unlawful drugs in any form (including cocaine, marijuana, methamphetamines, and hallucinogens), or used prescription drugs other than as prescribed (including sedatives, tranquilizers, or narcotics) in any form = Yes
Hidden
used unlawful drugs in any form (including cocaine, marijuana, methamphetamines, and hallucinogens), or used prescription drugs other than as prescribed (including sedatives, tranquilizers, or narcotics) in any form = No
3) been, or are currently a member of Alcoholics Anonymous, or Narcotics Anonymous?*
3) been, or are currently a member of Alcoholics Anonymous, or Narcotics Anonymous?*
- Yes
- No
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been, or are currently a member of Alcoholics Anonymous, or Narcotics Anonymous = Yes
Hidden
been, or are currently a member of Alcoholics Anonymous, or Narcotics Anonymous = No
Comments – Please provide details to any Yes responses above*
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Must fill out DAQ_Yes

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Prescription Medication
In the past two years, have you (a) been prescribed medication, or (b) taken medication prescribed by a physician, or (c) regularly used over-the-counter medication?*
In the past two years, have you (a) been prescribed medication, or (b) taken medication prescribed by a physician, or (c) regularly used over-the-counter medication?*
- Yes
- No
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In the past two years, have you (a) been prescribed medication, or (b) taken medication prescribed by a physician, or (c) regularly used over-the-counter medication = Yes
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In the past two years, have you (a) been prescribed medication, or (b) taken medication prescribed by a physician, or (c) regularly used over-the-counter medication = No
How many?*
Please list the medication details below:
Medication #1
Medication Name (copy from pharmacy label)*
Prescribing Physician (if any)
Reason*
Dosage/Frequency*
Date Last Taken (MM/YYYY)*
Medication #2
Medication Name (copy from pharmacy label)*
Prescribing Physician (if any)
Reason*
Dosage/Frequency*
Date Last Taken (MM/YYYY)*
Medication #3
Medication Name (copy from pharmacy label)*
Prescribing Physician (if any)
Reason*
Dosage/Frequency*
Date Last Taken (MM/YYYY)*
Medication #4
Medication Name (copy from pharmacy label)*
Prescribing Physician (if any)
Reason*
Dosage/Frequency*
Date Last Taken (MM/YYYY)*
Medication #5
Medication Name (copy from pharmacy label)*
Prescribing Physician (if any)
Reason*
Dosage/Frequency*
Date Last Taken (MM/YYYY)*
Additional Medications
Please provide the medication name, date last taken, prescribing physician name (if any), reason & dosage/frequency for any additional medications:*

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Hospitalization/Any Other Condition
In the past five years, have you consulted with a doctor or been hospitalized or treated by a health care provider for any other health condition?*
In the past five years, have you consulted with a doctor or been hospitalized or treated by a health care provider for any other health condition?*
- Yes
- No
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In the past five years, have you consulted with a doctor or been hospitalized or treated by a health care provider for any other health condition = Yes
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In the past five years, have you consulted with a doctor or been hospitalized or treated by a health care provider for any other health condition = No
How many times?*
Please list the details of each condition below:
Condition #1
Medical impairment, injury, illness or results of testing or examinations*
Name, Address & Phone of Hospital, and/or attending physician*
Month & Year (MM/YYYY)*
Duration*
Degree of Recovery*
Condition #2
Medical impairment, injury, illness or results of testing or examinations*
Name, Address & Phone of Hospital, and/or attending physician*
Month & Year (MM/YYYY)*
Duration*
Degree of Recovery*
Condition #3
Medical impairment, injury, illness or results of testing or examinations*
Name, Address & Phone of Hospital, and/or attending physician*
Month & Year (MM/YYYY)*
Duration*
Degree of Recovery*
Condition #4
Medical impairment, injury, illness or results of testing or examinations*
Name, Address & Phone of Hospital, and/or attending physician*
Month & Year (MM/YYYY)*
Duration*
Degree of Recovery*
Condition #5
Medical impairment, injury, illness or results of testing or examinations*
Name, Address & Phone of Hospital, and/or attending physician*
Month & Year (MM/YYYY)*
Duration*
Degree of Recovery*

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Replacement of Life Insurance or Annuities
The purchase of life insurance may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring.

Purchasing a new policy using funds from your existing policies or contracts to pay premiums due is also considered a replacement.

Please provide the following information.
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?*
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?*
- Yes
- No
Hidden
Are you considering discontinuing = Yes
Hidden
Are you considering discontinuing = No
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?*
Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?*
- Yes
- No
Hidden
Are you considering financing = Yes
Hidden
Are you considering financing = No
If purchasing an annuity, have you had another annuity exchange or replacement within the past 36 months?*
If purchasing an annuity, have you had another annuity exchange or replacement within the past 36 months?*
- Yes
- No
Hidden
If purchasing an annuity 36 months = Yes
Hidden
If purchasing an annuity 36 months = No
Why is the existing policy or contract(s) being replaced?*
Why is the existing policy or contract(s) being replaced?*
Hidden
Replaced/Converted Policy 1 = Yes (Text Box)
Hidden
Replaced/Converted Policy 2 = Yes (Text Box)
Hidden
Replaced/Converted Policy 3 = Yes (Text Box)

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Final Page
How did you hear about us?*
- Facebook
- Instagram
- Curtis Ray’s Book
- Online Search
- Podcast
- YouTube
- SunCor Financial Website
- Friend/Family
- Other
If "Other," please specify:*
Please list the agent you are working with. (If none, leave blank)
How long has the proposed insured known the agent? (XX Days/Weeks/Months/Years – If none, leave blank)*
How long has the proposed insured known the agent?
Phone
This field is for validation purposes and should be left unchanged.

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MPI™ Plan Application – OLD

Step 1 of 18 – Proposed Insured – Personal Info

Proposed Insured Personal Information

Foreign National

Financial Info

Policy Owner Information

Primary Beneficiary Information

If more space is needed, use the comments section below

Contingent Beneficiary Information

If more space is needed, use the comments section below

Comments

Insurance Info

Policy/Contract #1 Information

Policy/Contract #2 Information

Policy/Contract #3 Information

Policy/Contract #4 Information

Policy/Contract #5 Information

Proposed Insured(s) History

FYI: “Intention” is defined as an aim or plan. If you answer “Yes” to question 3, you will need to answer additional questions regarding your travel plans.

Foreign Travel

Health Info

Physician #1 Info

Physician #2 Info

Physician #3 Info

Physician #4 Info

Family History

Medical History

Drug/Alcohol Usage

Drug/Alcohol Use Questionnaire

Drug(s)

Alcoholic Beverage(s)

Deteriorating Health & Assisted living

Prescription Medication

Please list the medication details below:

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Additional Medications

Hospitalization/Any Other Condition

Please list the details of each condition below:

Condition #1

Condition #2

Condition #3

Condition #4

Condition #5

Replacement of Life Insurance or Annuities

Final Page