Mortgage Protection Insurance Application - NexBenefit Insurance Brokerage Service

Complete this form to apply for Mortgage Protection Insurance.

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We use your personal information only to help maintain and grow the business relationship you have with us.

Proposed Insured Information

First Name *

Last Name *

Social Security # *

Date of Birth (mm/dd/yyyy) *

Place of Birth (City, State) *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Alternate Phone

Email *

Is the proposed insured currently employed? *

Yes

Marital Status *

Single

Married

Gender *

Male

Female

Employer Name (or if Self-Employed, your business name)

Occupation

Annual Salary

Employer Address

Apt, suite, etc.

Country

City

State

Zip code

Description of Job Duties

Homeowner Information (if different from the Proposed Insured)

Owner's Name (Last, First, MI)

Relationship to Proposed Insured

Social Security # or Taxpayer ID #

Owner's Address (if mailing address is a P.O. Box, a street address is also required)

Apt, suite, etc.

Country

City

State

Zip code

How long at current address?

Primary Phone

Alternate Phone

Email Address

Date of Birth (mm/dd/yyyy)

Place of Birth (City, State)

Payer Information (if different from the Proposed Insured)

Payer's Name (Last, First, MI)

Relationship to Proposed Insured

Social Security # or Taxpayer ID #

Payer's Address (if mailing address is a P.O. Box, a street address is also required)

Apt, suite, etc.

Country

City

State

Zip code

How long at current address?

Primary Phone

Alternate Phone

Email Address

Date of Birth (mm/dd/yyyy)

Place of Birth (City, State)

Personal History

1. Within the past two (2) years, has the Proposed Insured:

a) made any flights as a pilot, student pilot, or member of a flight crew? (If Yes, complete Aviation questionnaire.) *

Yes

b) engaged in bungee/base jumping, parachuting, hang gliding, competitive skiing/snowboarding, diving, kayaking or any other hazardous sport/activity? (If Yes, complete Sports Activities questionnaire.) *

Yes

2. Has the Proposed Insured:

a) been convicted of reckless driving or driving under the influence of alcohol or drugs in the past five (5) years? *

Yes

b) had a driver’s license suspended or revoked within the past five (5) years or is currently under license suspension or revocation? *

Yes

c) been convicted of or plead guilty to more than two (2) moving violations in the past five (5) years? *

Yes

d) been convicted of or plead guilty to more than three (3) moving violations in the past three (3) years? *

Yes

3. Driver’s License Number(s) during the past five (5) years:

Name of Proposed Insured(s) on Driver’s License *

Driver’s License Number *

State Issued *

Name of Proposed Insured(s) on Driver’s License

Driver’s License Number

State Issued

Name of Proposed Insured(s) on Driver’s License

Driver’s License Number

State Issued

4) Within the past seven (7) years, has any Proposed Insured been convicted of, plead guilty to, or entered a plea of no contest to any felony? *

Yes

5) Is any Proposed Insured currently on probation or been placed on probation within the last twelve (12) months? *

Yes

6) Has any Proposed Insured ever been declined, postponed, rated, or modified for insurance? *

Yes

7) Within the next two (2) years, does any Proposed Insured intend to work or reside outside of the United States for more than thirty (30) days? (If Yes, where? Provide details below.) *

Yes

8. Personal History Details. Please provide details of all “Yes” answers in the area below. (Attach a separate sheet if more space is needed. Any additional sheet MUST be signed and dated by the applicable Proposed Insured/Owner to avoid amendments.)

Question #

Proposed Insured’s Name

Dates

Details

Question #

Proposed Insured’s Name

Dates

Details

Question #

Proposed Insured’s Name

Dates

Details

Question #

Proposed Insured’s Name

Dates

Details

Health History

List all Medications (Separated by Comma) *

Describe all Medical Conditions *

Coverage Request

Bank Draft Authorization

DRAFT DATE: (If no option is selected, Draft Date will default to the first option listed below) *

Upon issue and on the policy’s regular due date thereafter

Specific start date: (must be within 10 days of the Due Date and cannot be on the 29th, 30th, or 31st of the month. It may take up to 4 business days from the day we initiate the draft for your bank to process this transaction.)

Choose start date: (mm/dd)

ACCOUNT TYPE: (If no option is selected, Account Type will default to the checking account option) *

Checking Account

Savings Account

Financial Institution Name *

Account Number *

Routing Number *

Financial Institution Address *

Apt, suite, etc.

Country

City

State

Zip code

You have reached the end of the Mortgage Protection Insurance application.

Accept Terms *

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Complete this form to apply for Mortgage Protection Insurance.

Proposed Insured Information

Homeowner Information (if different from the Proposed Insured)

Payer Information (if different from the Proposed Insured)

Personal History

Health History

Coverage Request

Bank Draft Authorization

You have reached the end of the Mortgage Protection Insurance application.

Questions? Our support team is ready to help.