Submit an Express Case

    Case Information

    Agent Name *

    Agent Phone *

    Case Option *
    Express BASICExpress PLUS

    Express BASIC: PLEASE COMPLETE ALL SECTIONS OF THIS FORM AS ACCURATELY AS POSSIBLE. You have discussed the need for life insurance with the client and/or policy owner, and have run illustrations for the client. Once we receive this ticket, we will contact the client and complete the full life application, secure all signatures, and order & follow-up on all requirements. Once underwriting is complete and the offer is received, we will send the info back to the AGENT, and mail the policy to the AGENT for placement. You are agreeing to split the Agent-Level Compensation 90% Agent/Agency, 10% MWLB Express.

    Express PLUS: PLEASE COMPLETE ONLY SECTION 1 OF THIS FORM AS ACCURATELY AS POSSIBLE. Your client has requested life insurance from you, but you don't have the resources to discuss the case with him/her. Once we receive this ticket, we will contact the client and complete a quick needs anaylsis, run life illustrations, complete the full life application over the phone, secure all signatures, and order & follow-up on all requirements. Once underwriting is complete and the offer is received, we will present to the CLIENT, and mail the policy to the CLIENT directly for placement. You are agreeing to split the Agent-Level Compensation 75% Agent/Agency, 25% MWLB Express.

    Section 1 -- Proposed Insured Information

    First Name *

    Middle Initial

    Last Name *

    Street Address *

    City *

    State *

    Zip Code *

    Sex *

    Home Phone *

    Cell Phone

    Work Phone

    Client's EMail Address

    U.S. Citizen

    Birth Date *

    Last 4 of SSN

    Tobacco Usage

    Employer

    Approximate Annual Earned Income

    Section 2 -- Proposed Life Insurance

    Carrier

    Product

    Face Amount

    Riders Discussed

    Quoted Underwriting Class

    Quoted Annual Premium

    Section 3 -- Other Information

    Policy Owner

    Beneficiary

    Does the client have other coverage?

    Is this policy replacing coverage?

    Does the client take part in any hazardous sports activities?

    Does the client a private aviator?

    Does the client take any medication on a regular basis?

    Does the client have any surgical procedures that have been discussed but not completed?

    We will do our best to contact your client at the requested date and time. If you have discussed a date/time that works for your client, please enter it here:

    Upload Docs to MWLB Express

    Proposed Tele-Interview Date

    Proposed Tele-Interview Time

    Thank you for your business!