Easy Fact Finder Form Disability Insurance - Insuring Income - 5 - Insuring Income | Term Life Insurance Quotes

A Easy Fact Finder - Generic - AFF2019SD REF2019HHG BR2019PP DIBUNK201911 1DIQ2019EEW 1CLFF2019FF FFINTERNAL2019VV

Type of insurance you would like to apply for

Life Insurance

Disability Insurance

Do you know which disability insurance company/product you would like to apply for?

Yes

Not yet

Disability Insurance Product Name

Do you know which term life insurance company/product you would like to apply for?

Yes

Not yet

Death Benefit Amount

Term Length

Data from Life Insurance Quote Tool

Life Insurance Product

Life Insurance Company

Face Amount Quoted

Annual Premium Quoted

Health Class Quoted

Personal Questions

Height (feet, inches) *

Weight (pounds) *

Do you use Tobacco products? *

Yes

Details for Tobacco Use (type, frequency, duration) *

Are you a U.S. Citizen? *

Yes

Are you a permanent resident of the U.S.? *

Yes

What country are you a citizen of? *

VISA Type *

VISA Number

Has an immediate member of your family (father, mother, brother, sister) passed away due to a medical condition.

Yes

In brief, please let us know who, at what age, and what the cause was (this helps save you a lot of underwriting time):

Current Status

Home Address (physically where you are standing/living right this minute)

Home Address Street *

Home Address Street #2

City *

County

State *

Zipcode *

How long at that address? (Months, Years)

Have you lived at this address for at least 2 years?

Yes

Prior Home Address Street *

Prior Home Address Street #2

Prior City *

Prior State *

Prior Zipcode *

Is your mailing address the same as your present address? *

Yes

Mailing Address

Mailing Address Street *

City *

State *

Zipcode

Section

Are you moving in the next 90 days?

Yes

Street Address 1

Street Address 2

City

State

Zipcode

Tell us about your next exciting step - new state? new job? month you are moving?

Details *

Are you currently employed by, or seeking employment with, any company or entity which provides military, paramilitary, or security services outside of the United States? *

Yes

Details *

Have you been alerted to, received orders for, or had any indication of an overseas assignment or active service with any branch of the United States Military, including the Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or any reserve military unit? *

Yes

Details *

Beneficiary Details

Is your primary beneficiary a trust? *

Yes

Note: beneficiaries and percentages can be updated or changed any time you like once a policy is in force

Full name of primary beneficiary *

Date of Birth for Beneficiary (if known)

Relationship of primary beneficiary to insured *

SSN of Primary Beneficiary

The carrier you are applying for requires this, if you would like us to follow up via secure email or a cal, please put XXX-XX-XXXX here

Legal name of trust (taken direct from trust documents)

Date of trust (MM/DD/YYYY)

Trustee's complete legal name

WOULD YOU LIKE TO ADD A SECONDARY BENEFICIARY TO YOUR PROPOSED POLICY AT THIS TIME?

Yes

Legal Name of Secondary Beneficiary

Date of Birth for Secondary Beneficiary (MM/DD/YYYY)

Relationship of Secondary Beneficiary to Insured

Will the Secondary Beneficiary named above receive 100% of the proceeds in the event that the primary beneficiary has predeceased the insured?

Yes

Percentage of proceeds to go to Secondary Beneficiary #1

Legal name of Secondary Beneficiary #2

Date of Birth of Secondary Beneficiary #2

Relationship of Secondary Beneficiary #2 to insured

Percentage of proceeds to go to Secondary Beneficiary #2

Do you have any other life insurance in place?

Yes

Information for in force life insurance

Types of life insurance that you have in place

Group Life (through employer)

Individual

Group life amount (multiple of income or fixed amount)

Individual life amount (all carriers)

Do you intend to cancel any life insurance when this new policy is approved and ready to be put in place?

Yes

Which life insurance company is the insurance that you intend to replace with?

Policy Number

Year the policy was issued

General comments about replacing coverage (note is for us at Insuring Income and will not be entered on any applications)

Future Increase Options - Policy Details

Current Policy Number(s) - we can fill this in if you don't have it

Monthly Benefit that you would like to consider for purchase

Date for approximate income change

Do you have existing group disability insurance in place?

Yes

Approximate income increase from prior income

Details of Group Disability Insurance (percentage replacement, maximum monthly benefit)

Has your income increased by 20% or more since you purchased the policy or since you exercised future options?

Yes

Recent Pay Stubs and W2s (upload here)

Maximum file size: 134.22MB

Federal Income Tax Returns (upload here)

Maximum file size: 134.22MB

Do you have a signed contract for the new job?

Yes

Employment Contract (upload here)

Maximum file size: 134.22MB

Comments for job change, income change, graduation, etc. The more details the better.

Replacement Details - Disability

If you are replacing another disability insurance policy, there will be additional forms that will need to be signed.

Do you have or are you applying for other disability insurance? (includes group/employer sponsored and individual policies) *

Yes

List details in the following table (for "Type of coverage", indicate "group", "individual", "association", etc

Comments about existing insurance

Premium Payor Details

Who will be paying the premium for the insurance plan?

Insured/Self

Employer

OtherOther

What percentage of the premium will be paid by your employer?

Is the amount that your employer is paying toward the policy included in your taxable income?

Yes

Please ask your employer how they plan to treat the payments that are made on your behalf

Send premium notices to

Residence

Business

Other

Address for "Other"

Would you like to request DISABILITY INSURANCE proposals automatically on submit of this form?

Yes

Do you have any comments to add or questions? Please take advantage of this opportunity to message us through the form.

Attach pdf proposal of the plan that you want (optional, but helpful)

Maximum file size: 134.22MB

Premium dollar amount for plan that you are applying for (optional)

We commonly run multiple proposals and designs for disability insurance. This field can help us all to quickly identify the specific plan that you are interested in.

Do you remember what you searched for? Enter here if so (Thanks!).

If you don't mind, we ask that you let us know who sent you our way.

We always love letting the referring person know how much we appreciate spreading the word about what we do here at Insuring Income. Thank you from all of us.

Other (details)

Signature

Clear

If you are human, leave this field blank.

Insuring Income | Term Life Insurance Quotes | Disability Insurance Quotes

Easy Fact Finder Form Disability Insurance – Insuring Income – 5

Data from Life Insurance Quote Tool

Personal Information

Personal Questions

Home Address (physically where you are standing/living right this minute)

Mailing Address

Section

Employment Information

Carrier Specific Questions - Guardian Disability Insurance

Carrier Specific Questions - John Hancock

Beneficiary Details

Information for in force life insurance

Policy Design - Life

Policy Design - Disability

Future Increase Options - Policy Details

Replacement Details - Disability

Premium Payor Details

Financial Information