Quick Application Submission Form | MVP Financial Services

Agent must complete form with client: Select your MVP solutions expert, and the form will be submitted to them directly and a copy emailed to you as well. Your client will receive a phone call or a link via email from the carrier to complete all application and medical information, so be sure to let them know to expect this communication. If you have questions please contact your MVP expert, thank you for the opportunity to serve you!

Select your MVP expert here: *

* Required field(s)

Advisor information

Advisor name *

Date this form was completed *

Advisor email *

Advisor phone *

Broker / Dealer affiliation

Advisor SSN

Client information

Client 1

Insured name *

Date of birth *

Gender-at-birth *

Marital status *

Residence state *

Birth country / State *

U.S. citizen? *

Social Security Number *

Active duty member of the U.S. armed forces (incl. National Guard / Reserves)? *

How long at present address (months) *

Address *

City *

State *

Zip *

Country *

Mobile phone *

Preferred phone number *

Phone type *

Client email address *

Best day / time to contact client

Driver's license / state ID no. *

DL / ID state *

DL / ID exp. date *

Height (inches) *

Weight (lbs) *

Weight change of more than 10 lbs. in the last year? *

Tobacco / vape history? *

Ever been treated for cancer, heart disease, or stroke? *

Employment and income information

Client 1

Is the applicant employed? (Client 1) *

Annual income *

Estimated total assets *

Estimated total liabilities *

Net worth (assets minus liabilities)

Product information

For carriers marked with * the agent must be contracted first.

Carrier and product *

Term length *

GUL

Rate class applying for *

Face amount *

Term rider / length ($) *

Waiver of premium *

Other riders (please specify) *

Premium mode *

Premium quoted *

Purpose of this insurance (business, personal, income replacement, key person, etc.) *

If available, e-deliver policy? (If yes, a paper policy will not be issued) *

Owner and beneficiary information

Complete owner details only if the insured is not the owner.

Owner is a: *

Owner DOB or trust date *

Relationship to proposed insured *

SSN / tax ID *

Owner name *

Owner email *

Owner mobile *

Address *

City *

State *

Zip *

Country *

Primary beneficiaries

Primary beneficiary 1

Beneficiary name *

DOB *

Percent (%) *

Relationship *

SSN or Tax ID *

Phone *

Contingent beneficiaries? *

Replacement information

Client 1

Does the client currently own any life insurance? *

Proposed insured additional questions

Total household income — wages, salaries, investment returns, retirement payouts, welfare payments *

Will anyone other than the insured, family, or employer / business partner pay any premiums or obtain any interest in this policy? *

Will you submit another application (spouse, business partner, etc.) along with this one? *

Will any portion of the premiums be borrowed, loaned or otherwise financed? *

Is there an application pending in another company? *

Agent's relationship to the proposed insured *

Additional information

Requesting temporary insurance / conditional coverage? *

1. If Temporary Insurance (TIAA) or Conditional Coverage is available, it will be determined by most carriers at time of phone interview.

2. DO NOT COLLECT ANY MONEY-If requesting Temporary Insurance or Conditional Coverage, please submit a VOIDED check with this application. Alternatively, enter the following information:

3. Agent is NOT permitted to collect any premium from applicant

Preferred draft date (1–28)

Branch address

Branch phone

Applying for Conditional Coverage with Protective, I acknowledge that I have READ TO MY CLIENT the following statement: "Please be advised your account will be debited after the paramedical exam is complete. You will have no conditional insurance coverage until such time all the conditions of the Conditional Receipt have been satisfied." By checking the box I am confirming that I have read the above disclaimer to my client and they have verbally consented and confirmed their understanding of this information. (If box is not checked, Conditional Coverage will not be considered)

Has the client ever been declined, rated or postponed for life or health insurance? *

How long have you known the insured? (months) *

Did you meet with the client personally? *

Was an illustration presented? *

Advisor instruction / remarks / additional comments *

For business cases

Fair market value of business

Assets, liabilities and net worth of business

Additional comments

Authorization

By submitting this form to MVP Financial Services, I (writing agent) attest that I want this insurance request submitted to the carrier on behalf of the applicant. *