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Request your plan

Request your MPI® plan

1Proposed Insured

2Personal Details

3Juvenile Life Insurance Info

4Financial Info

5Beneficiary Info

6Policy Owner Information

7Insurance Info

8Proposed Insured(s) History

9Foreign National Foreign Travel Info

10Health Info

11Family History

12Medical History

13Deteriorating Health & Assisted Living

14Final Page

Proposed Insured

Name

First Middle Last

Has the Proposed Insured ever used a different name?

Yes

Please list all previously used full names:

First

Middle

Last

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

MM slash DD slash YYYY

Personal Details

Phone

Social Security Number

Is this an ITIN number?

Yes

Gender at Birth

Male

Female

Does the Proposed Insured have a Driver's License?

Yes

List

Drivers License #

Drivers License State

If not, please explain why:

US Citizen?

Yes

ATTENTION

Your Application will require additional review to continue. You may add additional details here and please schedule a follow-up meeting with one of our agents to complete.

Parent/Guardian Personal Details

Since Proposed Insured is less than 15 years old, please provide the parent/guardian email address and phone number for the Proposed Insured.

Phone

Juvenile Life Insurance Info

Total Amount of life insurance currently in force for Proposed Insured including Accidental Death Insurance?

Will the parent of the Proposed Insured be the Policy Owner (or a Trustee of the Trust that owns the policy?)

Yes

Please provide details of the intended owner of this policy

Parent Info

For multiple parents/guardians, click plus button to the right.

Parent/Guardian Full Name

Total Amount of life insurance in force including Accidental Death insurance?

Does the Proposed Insured live with the Proposed Owner?

Yes

Your Application will require additional information on the policy owner. You may add additional details here and please schedule a follow-up meeting with one of our agents to complete.

Does the Proposed Insured have any minor brothers or sisters?

Yes

Please Provide the name, age, and amount of current insurance coverage of all siblings in the comments section

Name

Age

Amount of insurance

Comments/Details

Financial Info

Employer

Occupation/Duties

Annual Individual Income

Include all forms of income, not just salary and wages

Cash savings

Contribution Frequency & Method?

Monthly Bank Draft

Annual Direct Bill

Semi-Annual Direct Bill

Quarterly Direct Bill

Regular contribution amount ($)

Regular contribution amount

MPI® is maximized through additional lump sum contributions made in the first two years of your policy. In addition to your regular contributions, do you have a lump sum amount that you'd like to accelerate your MPI® strategy with today?

Yes

What total amount can you make available over the next two years to jump start your MPI® strategy? NOTE: THE AMOUNT YOU ENTER HERE WILL BE DIVIDED EVENLY BETWEEN YEAR 1 AND YEAR 2.

Please provide as much information as you can regarding your lump sum amounts including source of funds and account types:

Within the last 5 years, have you filed for bankruptcy or had any judgements or liens filed against you?

Yes

If Yes, please explain and provide the filing and discharge dates

Beneficiary Info

Beneficiary Information

Full Name

% of Proceeds

Date of Birth

Relationship to Proposed Insured

Comments

Beneficiary Comments

Policy Owner Information

Is the Policy Owner a different person than the Proposed Insured?

Yes

Your Application will require additional information on the policy owner. You may add additional details below and please schedule a follow-up meeting with one of our agents to complete.

Policy Owner Type

Individual

Employer

Trust

Other

Insurance Info

Have you been offered cash or any other consideration for obtaining this policy?

Yes

Are you planning to enter into a finance agreement to pay any premiums due under this policy? (This is uncommon and does not apply to a monthly premium payment arrangement.)

Yes

Do you intend to sell or transfer ownership to a third party in the next five years, or have you sold or transferred ownership of a policy to a third party in the last five years?

Yes

In the past 12 months, have you applied for any life insurance or do you have any life insurance currently pending, excluding this application?

Yes

Do you have any existing life insurance or annuity contracts with the company or any other company?

Yes

Will this insurance replace or change any existing life insurance or annuity contract with the company or any other companies?

Yes

If you answered "Yes" to questions 4, 5 or 6, how many policies/contracts apply? (Populate with as many fields as needed from the answer)

Please provide the Insurance Policy and/or Annuity Contract details that apply. Please list any policies being replaced first:

Insurance Company Name

Death Benefit Amount

Business or Personal

Year Issued

Replaced/Converted

Pending

1035 Exchange

Proposed Insured(s) History

Have you had life insurance coverage declined, postponed or limited, or been denied reinstatement or asked to pay extra premium by any insurance company?

Yes

Have you engaged in parachuting, hang gliding, rock or mountain climbing, skydiving, SCUBA diving, cliff diving, organized vehicle or boat racing, BASE or bungee jumping within the last three years or plan such an activity in the next two years?

Yes

Do you have any intention of traveling or living outside the USA or Canada in the next two years?

Yes

Have you flown as a civilian pilot, student pilot or crew member within the last three years or plan such activity in the next two years?

Yes

Within the last five years, have you been convicted of two or more moving violations, been convicted of driving under the influence of alcohol or drugs or had a driver’s license suspended or revoked?

Yes

Have you been convicted of or currently awaiting trial for a felony, or have been incarcerated within the last 10 years?

Yes

Comments – Please provide details to any "Yes" responses above

Foreign National Foreign Travel Info

Are you employed in the United States?

Yes

Please provide the name and address of your employer and describe the duties you perform:

Employer Nane

Address

Duties

Please provide sources(s) of income while in the United States:

Do you plan to travel outside of the United States in the next two years?

Yes

Where do you plan to travel?

What is the purpose of this travel? (Select all that apply)

Business

Pleasure

How often? (# of times in the next two years)

Average period of time for each trip (XX Days/Weeks/Months)

What was the date of your last trip?

MM slash DD slash YYYY

Health Info

Height

(ft)

(in)

Weight

(lbs)

How many personal physicians have you seen in the relevant past, including your most recent visit?

Physician Info

Date Physician Last Seen (MM/YYYY)

State Reasons

Findings

Treatment

Family History

Do you have a deceased parent(s) and/or siblings?

Yes

List

Relationship (Father, sister, son, etc.)

Age of Death

Medical History

Please answer Y/N (If Yes, use the comments section to provide details)

Have you ever used any form of tobacco or any form of nicotine replacement therapy? (Including Vaping)

Yes

Do you currently use any form of tobacco or any form of nicotine replacement therapy? (Including Vaping)

Yes

Please describe and provide details regarding your use of tobacco and/or nicotine replacement therapy:

Have you ever been diagnosed with or tested positive for HIV or AIDS?

Yes

Have you ever received treatment for or been advised to seek treatment regarding any of the following:

any disease, or abnormal condition of the heart, circulatory system, or blood vessels, including high blood pressure, abnormal heart rhythm, pacemaker or defibrillator, valvular disease, or murmur, coronary artery blockage, chest pain, or stroke/mini-stroke?

Yes

any disease of the lungs, or respiratory system, including tuberculosis, asthma, chronic bronchitis, emphysema, sleep apnea, or shortness of breath?

Yes

any digestive system disease, including ulcer, abdominal, or stomach pain, liver, or gallbladder disease, hepatitis, cirrhosis, colitis, or other colon, intestinal, or rectal disorder?

Yes

any urinary, or reproductive system disease including protein, blood, or sugar in the urine; tumor, cysts, infection, or failure of the kidney; tumor, or disease of the prostate, testis, breasts, uterus, or ovaries?

Yes

any brain, nerve, or mental disorder, including convulsions/epilepsy, headaches, blackouts, tremors, balance disorders, multiple sclerosis, paralysis, dementia, depression, or schizophrenia?

Yes

any bone, or joint disorder, arthritis, or rheumatic conditions, including lupus, rheumatoid arthritis, scleroderma, fibromyalgia, or other bodily deformity, amputation, back, or spinal disorder?

Yes

any disease, or disorder of vision, or hearing?

Yes

cancer, tumor, blood/bleeding disorder, diabetes, thyroid, or other glandular/metabolic disorder?

Yes

IF “yes” to any of the above Comments

Please provide details to any Yes responses above

Drug/Alcohol Usage

In the past 10 years, have you:

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

used federally 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

been, or are currently a member of Alcoholics Anonymous, or Narcotics Anonymous?

Yes

Drug/Alcohol Questionnaire

Are you now using or have you in the last 10 years used any of the drugs below?

Opium derivatives: (Heroin, Morphine, Demerol, Codeine, Percodan, Dilaudid) Marijuana: (Hashish, Cannibis) Cocaine, Crack Sedatives and Tranquilizers: (Xanax, Librium, Valium, Quaalude, Dalmane, Placidyl) Barbiturates: (Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital) Amphetamines: (Methamphetamine (Meth), Benzedrine, Dexedrine, Adderall, Ritalin) Hallucinogens: (LSD, Mescaline, Peyote, Psilocybin, PCP) Antabuse, Methadone, Naloxone (Narcan)

Yes

Indicate which of the following you use(d):

Opium derivatives: (Heroin, Morphine, Demerol, Codeine, Percodan, Dilaudid)

Marijuana: (Hashish, Cannabis)

Cocaine, Crack

Sedatives and Tranquilizers: (Xanax, Librium, Valium, Quaalude, Dalmane, Placidyl)

Barbiturates: (Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital)

Amphetamines: (Methamphetamine (Meth), Benzedrine, Dexedrine, Adderall, Ritalin)

Hallucinogens: (LSD, Mescaline, Peyote, Psilocybin, PCP)

Antabuse, Methadone, Naloxone (Narcan)

Date last used:

MM slash DD slash YYYY

Frequency of use?

Amount of use?

How taken? (Oral, Injection, Inhaled, Smoked, Etc.)

How long did/have you used them?

Were any of the above drugs prescribed by a physician?

Yes

Which drugs prescribed by a physician?

Are you now using or have you in the last 10 years used any of the alcoholic beverages below?

Beer, Wine, Liquor

Yes

Date last used:

MM slash DD slash YYYY

Frequency of use?

Amount of use?

How long/have you used them?

Did you ever drink substantially more than at preset?

Yes

Date to:

MM slash DD slash YYYY

Date from:

MM slash DD slash YYYY

By how much more?

Why did you change your drinking habits?

Have you ever received medical treatment or been advised to seek treatment due to using drugs and/or alcohol?

Drugs

Alcohol

Drugs: Provide name(s) of doctor/facility, address and dates of treatment:

Alcohol: Provide name(s) of doctor/facility, address and dates of treatment:

Have you ever joined or attended a support group (such as AA or NA) because of:

Drugs

Alcohol

Drugs: Are you still an active member of a support group?

Yes

Alcohol: Are you still an active member of a support group?

Yes

Except those prescribed by a physician, are you now using or have you used during the last 10 years any other drugs not listed in questions 1 above?

Yes

Please provide details:

Have you ever been convicted (including DUI) of a crime related to the use or sale of:

Drugs

Alcohol

Drugs: Please list dates:

Alcohol: Please list dates:

Please provide any additional explanation or details:

Deteriorating Health & Assisted Living

In the past 12 months, have you experienced any of the following:

required the assistance of another person, or a device of any kind for bathing, dressing, eating, toileting, getting in and out of a chair or bed, or the management of bowel, or bladder problems?

Yes

received, or been advised by a member of the medical profession to have, any of the following types of care: nursing home, assisted living facility, adult daycare facility, home health care services, or physical, occupational, or speech therapy?

Yes

used any of the following: walker, wheelchair, electric scooter, oxygen, or catheter?

Yes

applied for, received, or are you currently receiving disability, hospital, or medical benefits from any insurance company, government, employer, or other source other than for maternity?

Yes

had an unexplained weight loss of greater than 10 pounds (other than due to diet or exercise)?

Yes

Comments – Please provide details to any Yes responses above

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?

Yes

Medications

Medication Name (copy from pharmacy label)

Prescribing Physician (if any)

Reason

Dosage/Frequency

Date Last Taken (MM/YYYY)

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?

Yes

Medical Hospitalization

Medical impairment, injury, illness or results of testing or examinations

Name, Address & Phone of Hospital, and/or attending physician

Duration

Degree of Recovery

Month & Year (MM/YYYY)

Final Page

How did you hear about us?

Facebook

Instagram

TikTok

Youtube

Friend/Family

Curtis Ray’s Books

Online Search

Podcast

CompoundInterest.com Website

Other

Please enter the name of the agent you are working with below. (If none, leave blank)

Any Additional Comments you’d like to include?

Business Hours

Monday-Friday: 9am to 5pm
Saturday: By Appointment
Sunday: Closed