Mass Mutual Application & Medical Process

Transcription

1 Mass Mutual Application & Medical Process Eligibility 1. Agent must be contracted with Mass Mutual before application will be processed. o Please contact Contracting@BarnumFG.com to get contracted 2. Whole Life & Term Products 3. All clients are eligible to use the EZ App EZ App Process 1. Agent submits EZ application for processing o For clients applying for a policy with a face amount greater than $50k, complete section A-F o For client applying for a policy with a face amount $50k or less, complete entire EZ Application 2. Within 1-2 business days the client will receive an requesting their e-signature 3. Agent will receive an e-signature request once the client signs o When the agent receives this , the application is NOT submitted. The agent must click the link to verify and submit the application 4. App is submitted fully to Mass Mutual only after both signatures are completed 5. Clients between the ages of and $1MM or less in face amount, will receive an to complete any additional medical questions o This will come from Mass Mutual CMI 6. Client will be contacted to schedule medical exams. 7. Policy is Underwritten

2 EZ-app Guide for Life & Disability Income Insurance This EZ-app Guide is designed to help you understand what information is needed when completing an application for insurance in EZ-app. It is not an application. When completing the actual application for insurance, either in paper or in EZ-app, all questions must be asked of, and answered by, the Proposed Insured(s) and/or Proposed Owner(s). Application type: Life & Disability Income (Review all sections) Life only (Review sections A-F) Disability Income only (Review sections A-B & G-H) A Proposed Insured Information Full name: Gender: Male Female Date of birth: Birth state: SSN/ITIN: Residential address: Phone 1: Home Work Cell Best time to call: Phone 2: Home Work Cell Best time to call: 1: 2: Type of citizenship: Resident U.S. citizen n-resident U.S. citizen Resident alien Other: Additional Citizenship Information (Non-U.S. Citizens only): Type of visa: Country of citizenship: How long have they lived in the U.S. on a full time basis? What members of their immediate family are full time residents in the U.S. or citizens of the U.S.? B Personal History More information will need to be provided at time of application if the Proposed Insured: Is currently disabled or applying for any disability benefits Has used tobacco or other nicotine containing products (e.g. cigarettes, e-cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or the patch) within the last 24 months Has ever been convicted of a felony, or is currently on parole or probation Has been convicted of operating a motor vehicle while under the influence within the last 5 years Has been found at fault in a motor vehicle accident, convicted of a moving violation or received a driver's license restriction or revocation (e.g. speeding ticket, suspended license, reckless driving or careless driving) within the last 3 years Has any recent/anticipated foreign travel Has any recent/anticipated military involvement Has any recent/anticipated aviation experience (e.g. pilot, student pilot, crew member) Has any recent/anticipated avocation participation (e.g. extreme sports) page 1 of 3 EZ-app Guide for Life & Disability Income Insurance 0816 LI7150

3 B Personal History (Continued) Physician name: Physician address: Date/timeframe/reason last seen: Occupation & job duties: Employer name & address: Annual earned income: $ Prior year: $ Annual unearned income: $ Prior year: $ Net worth: $ If juvenile, list all family members (including siblings, parents and legal guardians). For coverage, provide the total life insurance currently applied for or now in force with MassMutual or other companies. If none, more information will need to be provided at time of application. Relationship Name Age Group Coverage Non-Group Coverage $ $ $ $ C Owner Information (Life only; information needed if Proposed Owner is not Proposed Insured) Full name: Gender: Male Female Date of birth/date of Trust: Relationship to Insured: Trustee: Residential/legal address: D Beneficiary Information (Life only) Beneficiary 1 Type: Primary Secondary/Contingent t sure Full name: Date of birth/date of Trust: Relationship to Insured: Residential address: Beneficiary 2 Type: Primary Secondary/Contingent t sure Full name: Date of birth/date of Trust: Relationship to Insured: Residential address: Beneficiary 3 Type: Primary Secondary/Contingent t sure Full name: Date of birth/date of Trust: Relationship to Insured: Residential address: page 2 of 3 EZ-app Guide for Life & Disability Income Insurance 0816 LI7150

4 E Supplemental Information for Proposed Insured (Life only) If any of the questions below are answered Yes, additional information will be required at time of application: Have they been treated for, or had treatment recommended by, a health professional for cancer, heart attack, heart disease, chest pain, stroke, alcohol or drug use or immune system disorder within the past two years?... Have they been admitted to a hospital or medical facility, been advised to be admitted, or had surgery performed or recommended by a health professional other than for a normal pregnancy or childbirth within the past 90 days?... Have they had medical tests or examinations scheduled in the next 90 days except for pregnancy or childbirth?... F Other Life/Annuity Coverage on Proposed Insured (Life only) Policy # & Company Face Amount Product Issue Yr. Purpose Status Replace 1035x $ Business Personal Applied for In force $ Business Personal Applied for In force G Supplemental Information for Proposed Insured (Disability Income only) What percent of their duties include physical activity (e.g. climbing, crouching, lifting, etc.)? What state do they work in? How long have they worked for their current employer? If less than 2 years, what was their previous occupation and duration of employment? How many hours per week, on average, do they work? For the past 90 days, have they been continuously at work? If no, provide details of missed work, reduced hours or job restrictions/modifications: Is additional contributory group disability income coverage available through their employer? t sure If yes, do they have plans to participate in the future? t sure H Other Disability Income Coverage on the Proposed Insured (Disability Income only) Company Type* Issue Year Monthly Benefit Amount Benefit Period Waiting Period Employer Pay? Being Replaced? Replacement Date $ $ *Type of plan: Individual (I), Group (G) or Association (A) Reminders! At time of application, be sure to have the following on hand: Government issued ID (e.g. U.S. driver's license, passport, etc.) If setting up PAC for recurring payments, bank name, bank account number and routing number page 3 of 3 EZ-app Guide for Life & Disability Income Insurance 0816 LI7150

5 Application for Individual Life or Individual Disability Income Insurance (Part 2) To the Company as defined below: Massachusetts Mutual Life Insurance Company, 1295 State Street, Springfield, Massachusetts C.M. Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut Use this Application to provide additional information on the Proposed Insured. Complete all sections for all cases. A Personal Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : 1. Proposed Insured full legal name (First, MI, Last, Suffix): 2. Date of birth (mm/dd/yyyy): 3. Social Security Number or Taxpayer Identification Number: 4. Current height (Feet and Inches): Current weight (Pounds): 5. Has your weight changed by more than 10 pounds in the last year? If Yes, how much? Due to? Diet Other 6. Current primary physician name (First, MI, Last, Suffix): a. Physician business address (Street, Suite #, City & State or Country, ZIP/Postal Code): b. Physician Phone Number: ( ) -- c. Date last seen by physician and reason: 7. Family History. a. Complete all sections of the grid below, except Diagnosis, for all immediate family members (parents and siblings): Relative Diagnosis Include Age of Onset Age if Living Age at Death Cause of Death Father Mother Brother(s)/Sister(s) Have any of the family members listed above been diagnosed or treated by a member of the medical profession for: b. Heart Disease, vascular (blood vessel) disease or cancer?... c. A familial condition of the brain, muscles, nervous system or kidneys?... If 7b or 7c is Yes, complete Diagnosis in the table above. If additional space is required, use section C-Additional Information. B Personal History Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : If Proposed Insured answers Yes to any question, provide additional information in Supplement A. 1. Has the Proposed Insured used tobacco or other nicotine containing products (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or the patch): a. Within the last 12 months?... b. Within the last 24 months?... MassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales representatives. ICC12A US Application for Life or Disability Income Insurance (Part 2) 1

6 B Personal History Information continued 2. Is the Proposed Insured currently: a. Under treatment by a member of the medical profession or taking any prescription medications (other than contraceptives)?... b. Taking any herbal or non-prescription medication at least weekly?... c. Pregnant?... If Yes, expected delivery date: 3. In the past 10 years, has the Proposed Insured been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for a disease or disorder noted below: a. Chest pain, heart attack, high blood pressure, heart murmur, palpitations or any other disorder of the heart, arteries or veins?... b. A tumor or cancer including skin cancer, melanoma or colon polyps?... c. A disorder of the blood, spleen or immune system including anemia, blood clots, bleeding, immune deficiency, leukemia or lymphoma?... d. A disorder of the brain, spinal cord or nervous system including seizures, tremors, paralysis, dizziness, fainting, headaches, stroke or TIA (transient ischemic attack)?... e. Depression, anxiety, nervousness, stress, psychosis, suicide thoughts or attempts, anorexia or bulimia, post traumatic stress disorder, obsessive compulsive disorder, bipolar disorder, attention deficit hyperactivity disorder (ADHD) or other emotional disorder?... f. A disorder of the eyes, ears, nose, throat or sinuses including any partial or complete loss of hearing, vision or speech?... g. Asthma, allergies, shortness of breath, bronchitis, emphysema, chronic obstructive pulmonary disease (COPD), pneumonia, sleep apnea, tuberculosis or any other disorder of the respiratory system?... h. A disorder of the digestive system, liver, pancreas or gall bladder including hepatitis, jaundice, ulcers, intestinal bleeding, colitis, Crohn s disease (ileitis), recurrent indigestion, diarrhea or diverticulitis?... i. A disorder or impairment of the muscles, bones, joints, nerves, spine, neck or back including arthritis, gout, sciatica or amputations?... j. Epstein-Barr virus, Lyme disease, chronic fatigue syndrome, fibromyalgia, lupus or other rheumatologic disorder?... k. Diabetes or a disorder of the thyroid, pituitary or adrenal glands?... l. A disorder of the kidneys, bladder, prostate or urinary tract or findings of sugar, protein or blood in the urine?... m. A disorder of the skin including eczema or psoriasis?... n. A diagnosis of Human Immunodeficiency Virus (HIV) infection or Acquired Immune Deficiency Syndrome (AIDS)?... o. A disorder of the uterus, cervix, ovaries or breasts?... p. Multiple miscarriages, complicated pregnancy or infertility evaluation? In the last 10 years, has the Proposed Insured: a. Used cocaine, barbiturates, amphetamines, heroin, narcotics, stimulants, hallucinogens or other controlled substances or habit forming drugs not prescribed by a physician?... b. Received medical treatment, attended a program or been counseled for alcohol or drug abuse or been advised by a member of the medical profession to reduce the use of alcohol? In the last 5 years, has the Proposed Insured: a. Had an application for life, disability or health insurance declined, postponed, rated or restricted?... b. Had a sickness or injury for which a disability claim was made or payments, benefits or pension benefits were received? 6. In the last 3 years, unless previously stated on the application, has the Proposed Insured: a. Had a physical exam, check-up or evaluation by a member of the medical profession?... b. Had an injury treated by a health professional or medical facility?... c. Had an electrocardiogram, x-ray, blood test or other diagnostic test, excluding an HIV test?... d. Had surgery or been a patient in a hospital, clinic or other medical or mental health facility?... e. Been advised by a member of the medical profession to have surgery, medical treatment or diagnostic testing, excluding HIV testing that has not been completed?... ICC12A US Application for Life or Disability Income Insurance (Part 2) 2

7 C Additional Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Details. Provide additional details for questions answered Yes. Use Supplement A for additional space. Question Details and Medications Name of Physician Address of Physician D Agreements & Signatures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : I, the undersigned, have read the Application and all statements and answers as they pertain to me, and affirm that these statements and answers are true, complete and correctly recorded to the best of my knowledge and belief. The statements and answers in the application are the basis for any Policy issued by MassMutual and no information about me will be considered to have been given to MassMutual unless it is stated in the application. I hereby adopt all statements made in the application and agree to be bound by them. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. Signed at (City & State): Date: Signature of Proposed Insured: Printed Name: Date: Signature of Witness: Printed Name: Date: ICC12A US Application for Life or Disability Income Insurance (Part 2) 3

8 MEDICAL PRESET AGENT NAME AGENT # AA AGENT PHONE AGENT BELOW PLEASE INCLUDE ANY INSURANCE APPLIED FOR WITHIN THE LAST 13 MONTHS CARRIER TERM PERM DI CARRIER TERM PERM DI APPLICANT S PREFERRED DATE AND TIME ADDRESS WHERE EXAM WILL TAKE PLACE: 1 ST CHOICE 2 ND CHOICE PLEASE NOTE: Please advise your client(s) that their appointment is NOT confirmed until it is confirmed by the Examiner. The Examiner will contact the client directly to confirm the appointment. Examiner will also contact the client again 24 hours before the appointment as a reminder and to relay appointment preparation requirements (i.e. water intake, fasting, etc.)