MibApp - Life MIB

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Life Mib make Life Insurance approval easy and convenient, for everyone, not just for the young and healthy.

Budget, Coverage Amount, and type of Policy.

Let's start with your budget *

Coverage Amount *

Do you have a preferance type of coverage *

Medical History

Care to answer some health questions, for better cost and benefits. *

Medical History

Height: *

Weight(LBS): *

Have you used any form of tobacco or nicotine products including cigarettes, cigars, pipes, e-cigarettes, chewing tobacco, snuff, nicotine patches or nicotine gum, within the last 24 months? *

If you are not a current nicotine user, have you used any nicotine products in the past? *

If Yes, what was your last date of use? *

Have you ever been

1. Diagnosed by a member of the medical profession or tested positive for Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? *

2. Diagnosed or treated by a member of the medical profession for specified symptoms such as: immune deficiency, recurrent fever, unexplained weight loss, fever of unknown origin, severe night sweats, unexplained infections or skin lesions, unexplained swelling of the lymph glands, Kaposi’s Sarcoma, or Pneumocystis Carinii Pneumonia? *

3. Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Stent Placement, Valvular Heart Disease, Cardiomyopathy, Congestive Heart Failure, Congenital Heart Disease, Stroke, Transient Ischemic Attack (TIA)/Mini Stroke, abnormal heart rhythm, Cerebral, Aortic or Thoracic Aneurysm, or Abdominal Aortic Aneurysm?.Chronic Lung Disease (except Asthma), including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Sarcoidosis, or Cystic Fibrosis? *

4. Major Depression, Bipolar Depression, Schizophrenia, Alzheimer’s Disease, Dementia, Down Syndrome, Autism, mental incapacity, suicide attempt, or any other disease of the central nervous system? *

Have you ever been

5. Chronic Kidney Disease, End-Stage Renal Disease, Renal Insufficiency, or any condition within the last 5 years that required dialysis? *

6. Parkinson’s disease, Sickle Cell Anemia, Lou Gehrig’s Disease (ALS), Muscular Dystrophy, Demyelinating Disease including Multiple Sclerosis, Huntington’s Disease, Hydrocephalus, Quadriplegia, or Paraplegia? *

7. Liver Disease, Cirrhosis, Hepatitis B or Hepatitis C, Crohn’s Disease, or Ulcerative Colitis? *

8. Cancer, Leukemia, Melanoma, any tumor (benign or malignant) of the brain, or any other cancer (except basal cell cancer)? *

9. Rheumatoid Arthritis, Systemic Lupus, or Scleroderma? *

10. An organ transplant? *

11. Diabetes requiring insulin in any form or with complications such as Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve), or Peripheral Vascular Disease (PVD or PAD)? *

12. Do you currently have a primary care physician? *

Personal History

1. In the next 2 years do you intend to engage in any motorsports racing; boat racing; parachuting/skydiving; hang gliding; base jumping; rock or mountain climbing; cave diving, underwater photography, canyoning, or Scuba diving over 100 ft.? *

2. Within the past 10 years, have you been convicted of, or are you currently awaiting trial for, any felony? *

3. Are you currently on or have you been released from probation, parole, or other court-ordered supervision with the last 2 years? *

4. In the past 10 years, have you: Used heroin, morphine, other narcotics, ecstasy, opium derivatives, marijuana, cocaine, crack, barbiturates, amphetamines, methamphetamines, or hallucinogens or any other illegal, restricted or controlled substances; or been treated? *

5. Within the past 5 years, have you been convicted, pled guilty, or entered into a plea agreement for driving under the influence of drugs or alcohol or reckless driving, or had 3 or more moving violations or had your driver’s license suspended or revoked? *

6. Do you currently hold a valid driver’s license? *

License Number *

License State *

Provide Details *

Personal History Continue

Are you currently employed? *

Occupation *

Annual Salary *

What's the source of your income? *

Annual Income *

Personal History

Do you have any existing annuity or life insurance or have any application pending tor such coverage with this Company or any other company? *

Will the life insurance policy being applied for replace or change any annuity or life insurance coverage in force or pending? *

Are you a united States Citizen or do you have Permanent Legal Resident (Green Card) status? *

Personal Information

First Name: *

Last Name: *

Date of Birth: *

Select Gender *

Country of Birth: *

State of Birth: *

Street Address: *

City: *

Email: *

State: *

Zip Code: *

Primary phone number: *

Secondary phone number: *

Social Security Number: *

Beneficiary Details

First Name:

Middle Name:

Last Name

Relationship

Almost done

Our underwriting requires a payment method on file to process your application. No payment will be process until application is approved.

First Name: *

Middle Initial: *

Last Name: *

Routing Number: *

Account number: *

Bank Name: *

Account Type: *

Disclaimer

Life Mib Llc does not underwrite any insurance policy described on this website. Any insurance policy premium quotes or ranges displayed are non-binding. The final insurance policy premium for any policy is determined by the underwriting insurance company following application.

By clicking "Submit Application”, you agree to Life Mib, llc Privacy Policy and Terms of Use, and that we may contact you at the phone number and email address provided above. Your permission includes using an autodialer. Your consent to receive these calls or emails isn't required to purchase a policy, and we don't share your contact information with third parties.

Confirm you have read the disclaimer

Life Mib make Life Insurance approval easy and convenient, for everyone, not just for the young and healthy.

Budget, Coverage Amount, and type of Policy.

Medical History

Medical History

Have you ever been

Have you ever been

Personal History

Personal History Continue

Personal History

Personal Information

Beneficiary Details

Almost done

Our underwriting requires a payment method on file to process your application. No payment will be process until application is approved.

Disclaimer

DISCLAIMER