Home Secure

Document Sample
Home Secure Powered By Docstoc
					                                       Client Pre-Qualification Worksheet
                                       Home SecureTM – INSpeed® Application Enrollment Process
                                       (For Informational Use ONLY - This is NOT an application)


  INSpeed® Call Center: 1-888-252-3277
        Interview Date:
           Owner/Insured must be the same person – the Applicant
           Will the premium payor be someone other than the Applicant?                                Yes (must be available)  No
           Has the Applicant closed on a mortgage within the past 24 months?                          Yes    No (not eligible)
Who provides
to CCR?
Agent               What State is Applicant located?                                                Select State
Agent               What City is Applicant located?

Applicant           Social Security #
Applicant           Gender                                                                              Male       Female
Applicant           Applicant          First Name
Applicant                              Middle Name or Initial
Applicant                              Last Name
Applicant                              Suffix                                                       None
Applicant           Date of Birth
Applicant           Applicant born in the U.S.?                                                        Yes       No
Applicant                              If Yes, select State of Birth                                Select State
                                       If No, type in Country of Birth
Applicant           Mailing Street Address
Applicant           City
Applicant           State                                                                           Select State
Applicant           ZIP Code
Applicant           Home Telephone
Applicant           Best time to call
Applicant           E-mail address
Applicant           (If Florida) Does Applicant wish to designate a secondary addressee?                Yes        No
Applicant                              Secondary Addressee Name
Applicant                              Secondary Addressee Street Address
Applicant                              Secondary Addressee City
Applicant                              Secondary Addressee State                                    Select State
Applicant                              Secondary Addressee ZIP Code
Applicant           Marital Status                                                                  Other
Applicant           Occupation
Applicant           Do you have a valid driver’s license?                                               Yes      No
Applicant                              What is the reason for NO license?                           Never Licensed
Applicant           Driver’s License State                                                          Select State
Applicant           Driver’s License Number
Applicant           Within the past 12 months, have you used any form of tobacco or
                    nicotine product, including cigarettes, cigars, pipes, chewing tobacco,              Yes        No
                    snuff, marijuana, or tobacco use cessation aids?




                                                The Baltimore Life Insurance Company
                                      10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                           Replacement business will not be accepted AR, FL, SD, and WA.
                                          For more information on Home Secure www.baltlife.com/homesecure/
  Form ad8319-Rev. 4/27/2011
  Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process




Applicant           Primary Beneficiary #1     First Name
Applicant                                      Middle Name or Initial
Applicant                                      Last Name
Applicant                                      Suffix                                                  None
Applicant                                      Relationship to Applicant?                              Other
Applicant                                       Are you able to provide their Social Security
                                                #?
Applicant                                      Is this the only primary beneficiary?                         Yes   No
Applicant                                      Do you wish to distribute proceeds equally?                   Yes   No
Applicant                                      Percentage of proceeds for this beneficiary?

Applicant           Primary Beneficiary #2     First Name
Applicant                                      Middle Name or Initial
Applicant                                      Last Name
Applicant                                      Suffix                                                  None
Applicant                                      Relationship to Applicant?                              Other
Applicant                                       Are you able to provide their Social Security
                                                #?
Applicant                                      Percentage of proceeds for this beneficiary?
Applicant                                      Are there any other primary beneficiaries?                    Yes   No

Applicant           In addition to the primary beneficiaries, will there be any contingent                   Yes   No
                    beneficiaries?

Applicant           Contingent Beneficiary #1 First Name
Applicant                                     Middle Name or Initial
Applicant                                     Last Name
Applicant                                     Suffix                                                   None
Applicant                                     Relationship to Applicant?                               Other
Applicant                                     Is this the only contingent beneficiary?                    Yes      No
Applicant                                     Do you wish to distribute proceeds equally?                 Yes      No
Applicant                                     Percentage of proceeds for this beneficiary?

Applicant           Contingent Beneficiary #2 First Name
Applicant                                     Middle Name or Initial
Applicant                                     Last Name
Applicant                                     Suffix                                                   None
Applicant                                     Relationship to Applicant?                               Other
Applicant                                     Percentage of proceeds for this beneficiary?
Applicant                                      Are there any other contingent beneficiaries?                 Yes   No

Applicant           Contingent Beneficiary #3 First Name
Applicant                                     Middle Name or Initial
Applicant                                     Last Name
Applicant                                     Suffix                                                   None
Applicant                                     Relationship to Applicant?                               Other
Applicant                                     Percentage of proceeds for this beneficiary?
Applicant                                      Are there any other contingent beneficiaries?                 Yes   No

Applicant           Home Loan Date                                                                     MMYYYY
Applicant           Home Loan Amount (Financed)
Applicant           Home Loan Payment (incl. property taxes, homeowners ins., escrow
                    items)

                                                 The Baltimore Life Insurance Company
                                       10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                           Replacement business will not be accepted AR, FL, SD, and WA.
                                          For more information on Home Secure www.baltlife.com/homesecure/
  Form ad8319-Rev. 4/27/2011
  Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process

Applicant           Mortgage Lender Name

Agent               Face Amount:
Agent               Term Period:                                                                         Select Period
Agent               Benefits applied for:        Waiver of Premium                                          Elect
Agent                                            Return of Premium                                          Elect
Agent                                            Accelerated Death Benefit                                  Elect      Decline
                                                   (automatically included, where available)
Agent                                            Disability Income                                             Elect

DISABILITY INCOME QUESTIONS:
Agent         1. Applicant’s current gross monthly income from occupation
Agent         2. Amount of monthly DI current in force
Agent         3. Monthly income being applied for

Applicant                                                                                                      Yes
                    4. Is your average work week 30 hours or more?
                                                                                                               No (not eligible)
Applicant           5. Does your employer provide worker’s compensation or any other form                      Yes
                    of on-the-job disability coverage for work-related sicknesses or injuries?                 No (not eligible)
Applicant           6. Are you engaged in any of the following occupations: postal, city,
                                                                                                               Yes (not eligible)
                    county, state, or federal employee, railroad, law enforcement, fire fighter,
                                                                                                               No
                    underground miner, or active in the military, National Guard or reserve?
Applicant           7. Have you within the past 12 months, received disability benefits of any
                    kind or been disabled for more than 30 days, other than pregnancy, or
                                                                                                               Yes (not eligible)
                    have you applied to receive, or are you eligible to receive disability
                                                                                                               No
                    payment compensation or a benefit from any source as a result of illness
                    or injury?
Applicant           8. Do you need supervision and/or assistance of any kind with bathing,
                                                                                                               Yes (not eligible)
                    bowel or bladder function, dressing, eating, using the toilet or
                                                                                                               No
                    transferring?

Applicant           R1. Do you have existing life insurance or annuities or pending in this or                 Yes
                    any other company?                                                                         No
Applicant           R2. Will this policy, if issued, replace or modify any existing life
                                                                                                               Yes
                    insurance or annuities in this or any other company? This includes the
                                                                                                               No
                    use of dividends or other policy values.
Applicant           R3. Are you considering discontinuing making premium payments,
                                                                                                               Yes
                    surrendering forfeiting, assigning to the insurer, or otherwise terminating
                                                                                                               No
                    your existing policy or contract?
Applicant           R4. Are you considering using funds from your existing policies or                         Yes
                    contracts to pay premiums due on the new policy or contract?                               No
Applicant           R5. What is the reason for replacing your existing policy?

  If any one of the questions R1, R2, R3, or R4 were answered YES, Applicant must provide:

                                      Company Name                                                                     Replace or Modify?
                                                                                                                           Yes      No
                                                                                                                             Yes    No
                                                                                                                             Yes    No




                                                 The Baltimore Life Insurance Company
                                       10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                             Replacement business will not be accepted AR, FL, SD, and WA.
                                            For more information on Home Secure www.baltlife.com/homesecure/
  Form ad8319-Rev. 4/27/2011
   Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process



Who provides
to CCR?
Applicant           Your height
Applicant           Your weight
Applicant           Weight gained or lost in the past year (in pounds)

PRE-QUALIFICATION QUESTIONS:
Applicant                                                                                                      Yes (not eligible)
            1. Do you currently require the use of a wheelchair?
                                                                                                               No
Applicant         2. Have you been told by a medical professional you have a terminal illness or 12 months     Yes (not eligible)
                  or less to live, or been advised to use hospice services?                                    No
Applicant         3. Have you been convicted more than once of driving under the influence of alcohol or       Yes (not eligible)
                  drugs?                                                                                       No
Applicant         4. Have you ever tested positive for HIV, the Human Immunodeficiency Virus, or have
                                                                                                               Yes (not eligible)
                  you ever been diagnosed by a medical professional as having Acquired
                                                                                                               No
                  Immunodeficiency Syndrome or AIDS, or AIDS Related Complex?
Applicant         5. Have you ever had more than one occurrence of cancer, lymphoma, or melanoma other         Yes (not eligible)
                  than basal or squamous cell skin cancer?                                                     No
Applicant         6. Have you ever been treated by a medical professional or been diagnosed as having any
                  of the following: ALS or Lou Gehrig’s Disease, Huntingdon’s Disease, Multiple
                  Sclerosis, Muscular Dystrophy, Myocardial Infarction or heart attack, cardiomyopathy or
                  weakened or poorly functioning heart muscle, Systemic Lupus Erythematosus,                   Yes (not eligible)
                  Scleroderma, cystic fibrosis, sickle cell anemia, Chronic renal failure or advised to        No
                  undergo dialysis, Hepatitis C, cirrhosis or other chronic liver disease, schizophrenia,
                  psychosis, dementia, Alzheimer’s, Bi-polar disorder, mental retardation, Down
                  Syndrome, or Parkinson’s disease?
Applicant         7. Have you ever had or been advised to have an organ transplant, coronary or heart
                                                                                                               Yes (not eligible)
                  surgery, angioplasty or stent placement, pacemaker or defibrillator implantation, heart
                                                                                                               No
                  valve repair or replacement, or amputation due to disease?
Applicant         8. In the past 10 years, have you received treatment or been advised to seek treatment for   Yes (not eligible)
                  alcoholism or drug addiction?                                                                No
Applicant         9. In the past 5 years, have you been confined to a nursing facility, had carotid artery
                                                                                                               Yes (not eligible)
                  surgery, had Gastric Bypass or Lap Band surgery, used or been advised to use
                                                                                                               No
                  supplemental oxygen or insulin?
Applicant         10. In the past 5 years, have you used substances such as cocaine, heroin, amphetamines,     Yes (not eligible)
                  barbiturates or hallucinogens?                                                               No
Applicant         11. In the past 5 years, have you been convicted of a felony or been on parole or            Yes (not eligible)
                  probation?                                                                                   No
The following questions determine eligibility for coverage. A "yes" response is not an automatic
disqualification.
Applicant          1. Within the past 2 years, have you engaged in or, do you plan to engage in any aviation
                                                                                                               Yes        No
                   activity other than as a fare-paying passenger on commercial airlines?
Applicant          2. Within the past 2 years, have you engaged in or, in the next 2 years do you plan to
                   engage in any form of scuba diving, hang-gliding, cave exploration, parachuting,
                                                                                                               Yes        No
                   mountain, rock or ice climbing, bungee jumping, mixed martial arts, organized motor
                   racing, or any other hazardous or extreme sports?
Applicant          3. Within the past 5 years, have you been convicted of driving under the influence of
                                                                                                               Yes        No
                   alcohol or drugs or have you had more than three motor vehicle moving violations?
Applicant          4. Within the past 5 years, have you had an application for life, health, or disability
                                                                                                               Yes        No
                   insurance declined, postponed, rated, or denied reinstatement?




                                                  The Baltimore Life Insurance Company
                                        10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                            Replacement business will not be accepted AR, FL, SD, and WA.
                                           For more information on Home Secure www.baltlife.com/homesecure/
   Form ad8319-Rev. 4/27/2011
    Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process



For purposes of the next section of questions, the terms "treated" and "diagnosed" mean that any of
the following have occurred within the past 10 years: you have been treated or you have been
diagnosed by a medical professional, as having, or you have received follow-up care, including
observation and monitoring.
Applicant         5. Within the past 10 years, have you been treated for or diagnosed as having any heart
                  disorder, including, abdominal aortic aneurysm, angina (chest pain), congestive heart
                                                                                                                 Yes        No
                  failure, abnormal heart rhythm, arrhythmia, heart murmur, any blockage or narrowing of
                  the arteries, stroke, transient ischemic attack, TIA or mini-stroke?
Applicant         6. Within the past 10 years, have you been treated for or diagnosed as having diabetes,
                  anemia, blood or platelet disorders, liver disease including hepatitis, kidney disease,        Yes        No
                  other than kidney stones, Crohn’s disease, Ulcerative Colitis, or pancreatitis?
Applicant         7. Within the past 10 years, have you been treated for or diagnosed as having Cancer,
                                                                                                                 Yes        No
                  Leukemia, Lymphoma, or Melanoma?
Applicant         8. Within the past 10 years, have you been treated for or diagnosed as having memory
                  loss, seizures, cerebral palsy, any other disease or disorder of the brain or nervous          Yes        No
                  system, or neuro-muscular disorders, including paralysis?
Applicant         9. Within the past 10 years, have you been treated for or diagnosed as having sleep
                  apnea, asthma, rheumatoid arthritis, Chronic Obstructive Pulmonary Disease or COPD             Yes        No
                  or other respiratory disorder?
Applicant         10. Within the past 10 years, have you been treated for or diagnosed as having any
                  disease or disorder of the breast or prostate, including an elevated PSA or prostate           Yes        No
                  screening test?
Applicant         11. Within the past 10 years, have you been treated for or diagnosed as having
                                                                                                                 Yes        No
                  hypertension, high blood pressure or elevated cholesterol?
Applicant         12. Within the past 10 years, have you been treated for or diagnosed as having
                  depression, eating disorders or any other psychological or emotional disorders requiring       Yes        No
                  hospitalization or treatment by a psychiatrist?
Applicant         13. Do you currently have any medical testing pending or procedures that have not yet
                                                                                                                 Yes        No
                  been completed, other than routine lab work?
Applicant         14. Other than as already disclosed above, are you currently taking any medication or
                                                                                                                 Yes        No
                  receiving medical or mental health treatment of any kind?

Applicant           Do you have a primary physician?                                                             Yes        No
Applicant           Physician Name
Applicant           Physician’s City
Applicant           Physician’s State                                                                        Select State
Applicant           Phone (optional)

Agent               Premium Mode                                                                             Select Mode

                    If Payor is other than the Applicant:
Payor               Payor First Name
Payor                        Middle Name or Initial
Payor                        Last Name
Payor                        Suffix                                                                          None
Payor               Relationship to Applicant?                                                               Other
Payor               Social Security #

Payor/Applicant     Name of Account Holder as it appears on bank records
Payor/Applicant     Bank Name
Payor/Applicant     Type of Account                                                                             Checking         Savings
Payor/Applicant     9-Digit Bank Routing Number
Payor/Applicant     Your Bank Account Number
Payor/Applicant     Is a different future draft date being selected?                                             Yes        No
Payor/Applicant             Future Draft Date (1st – 28th)

                                                 The Baltimore Life Insurance Company
                                       10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                           Replacement business will not be accepted AR, FL, SD, and WA.
                                          For more information on Home Secure www.baltlife.com/homesecure/
    Form ad8319-Rev. 4/27/2011
   Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process



Agent              1. Based on your knowledge, does the Applicant have existing life insurance or annuities?       Yes      No
Agent              2. Do you have knowledge or reason to believe that replacement of existing life insurance or
                                                                                                                   Yes      No
                   annuities may be involved?
Agent                                                                                                              Yes
                   3. If replacement is occurring, do you certify that this replacement is within the guidelines
                                                                                                                   No
                   provided by Baltimore Life?
                                                                                                                   Not Applicable
Agent              4. Would you like the policy mailed to the applicant?                                           Yes       No

   Notes:




                                                  The Baltimore Life Insurance Company
                                        10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                            Replacement business will not be accepted AR, FL, SD, and WA.
                                           For more information on Home Secure www.baltlife.com/homesecure/
   Form ad8319-Rev. 4/27/2011
Client Pre-Qualification Worksheet Home SecureTM – INSpeed® Application Enrollment Process

                                               Preparation Checklist
                             Home Secure – INSpeed Application Enrollment Process
Date:                         Applicant Name:

         Have all disclosures been read or emailed to the Applicant?
              Notice and Disclosure
              Conditional Receipt
              Accelerated Death Benefit Disclosure, if applicable
              Replacement form, if applicable (no replacement business accepted in AR, FL, SD, WA)
              Pennsylvania and Maine Disclosure Statements, if applicable
                      Disclosures e-mailed to New Business? e-mail: hs@baltlife.com
              Buyer’s Guide (GA, ME, NH, WI only)

         Has the Applicant been Pre-Qualified?
              Mortgage origination within past 24 months
              Height/Weight; weight gain or loss
              Application – Section One, questions 1-11; any “yes” responses will disqualify applicant
              Prescription Drug List
              Health Conditions List
              Disability income rider: Applicant’s occupation and certain responses to the DI questions 4-8 will
              disqualify applicant for DI

         If Payor is other than the Applicant, is Payor accessible during INSpeed call?
              And ready to provide: (1) social security #, bank account #, bank routing #, bank name

         Policy and rider information determined?

         Proposed premium and modal payment agreed upon?

         Is Applicant prepared to provide the CCR with the following?

              Driver’s License #                                                Health information including durations, medications,
              Primary and contingent beneficiary                                dosages
              information                                                       Primary physician – name, city, state
              Mortgage loan date, amount, payment, and                          Bank account #, bank routing #, bank name
              lender                                                            Bank draft date
              Existing, pending or replaced policy                              E-mail address
                   information – Company Names                                  In Florida only: secondary address information, if
                                                                                necessary


         Advised Applicant that they may receive e-mail with secure link to the disclosures?




                                              The Baltimore Life Insurance Company
                                    10075 Red Run Boulevard, Owings Mills, Maryland 21117-4871
                                        Replacement business will not be accepted AR, FL, SD, and WA.
                                       For more information on Home Secure www.baltlife.com/homesecure/
Form ad8319-Rev. 4/27/2011

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:12/19/2011
language:English
pages:7