Outside Sales Application

Last Page

Welcome!

I’ll ask a few quick questions to start your term life insurance application

First Name? *

Last Name? *

Email address? *

Each applicant must use a unique email address. If you’ve used this email on a prior application, please use a different one for this applicant. Our system matches applications by email, and reusing it may replace existing information.

Phone number? *

Each applicant must use a unique phone number. If you’ve used this phone number on a prior application, please use a different one for this applicant. Our system matches applications by phone number, and reusing it may replace existing information.

What’s your home address? *

Zip Code *

Do you currently have life insurance? *

Please choose one of the options below *

By checking this box, I provide my express written consent to receive emails, phone calls, text messages, and artificial or pre-recorded messages from Magen Family LLC regarding this form and any life insurance coverage applied for on my behalf by Magen Family LLC.

Personal Information

Did you have any other names in the last 5 years? *

Yes

Please specify your other name(s) *

How many years have you lived at your current address? *

Prior address? *

Date of birth? *

Gender *

Male

Female

Place Of Birth *

Country Of Birth *

State Of Birth *

Citizenship? *

Please specify your citizenship status *

Upload Green Card

Maximum file size: 10 MB

Marital status? *

Amazing were moving right along! Please tell me what you do for a living.

Are you employed? *

Yes

What is your current status? *

Please specify: *

Employer name? *

Employer Address? *

Occupation? *

Job Title? *

Years Employed? *

Prior Employer Name *

Prior Employer Address? *

Prior Occupation *

Prior Job Title *

Prior Job Years Employed *

Annual Household Gross income amount? *

Do you receive bonuses? *

Yes

Annual bonuses amount *

Average Monthly Expenses *

Beneficiary Information

Beneficiary name? *

Relationship to insured? *

Please specify the relationship to the insured *

Beneficiary DOB? *

Do you have any secondary beneficiary? *

Yes

Secondary beneficiary name *

Relationship to insured? *

Secondary Beneficiary DOB? *

Policy and Coverage

Now let’s set your coverage details. Longer terms or higher amounts mean higher premiums — you can adjust these later before buying.

Policy type? *

Amount applied for? *

Do you have any assets? *

Yes

Total Assets Value *

Assets Type *

Any Liabilities? *

Yes

Total Liabilities Value *

Liabilities Type *

Policy Payment Option *

Existing and Prior Insurance

Current Life Insurance Company *

Type *

Term, Whole, Etc.

Current Coverage Amount *

Year issued *

Any additional Policies?

Yes

0.00

Have you ever had insurance declined or rated? *

Yes

Reason For decline or Rate? *

Reason for replacing existing insurance *

Health Information

Do you have any existing medical conditions? *

Yes

Please specify your medical condition(s) *

Have you had any surgeries or medical procedures in the past 10 years? *

Yes

Please specify your surgery(ies) or medical procedure(s) *

Are you currently taking any prescriptions? *

Yes

Please specify your prescription(s) *

ID *

Please specify your ID type *

ID State *

ID number *

ID Expiration Date *

Upload ID

Maximum file size: 10 MB

Social Security Number? *

Additional Information

Add anything you’d like us to know or clarify about your application.