Individual Under 65 Plan Options - Midwest Insurance Brokerage Services Inc

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Individual Under 65 Plan OptionsCollin Hajduk2022-09-22T19:51:21-05:00

Individual Under 65 Plans

SEP Documentation For Enrollment

Step 1 of 7

14%

Requested Effective Date
MM slash DD slash YYYY
Producer Information
Producer Name*
First Last
Producer Phone Number*
Producer Email*
Enter Email Confirm Email
How many years has the producer known the applicant?*
- 1 Year
- 1-3 Years
- 3+ Years

Insured Personal Information
Insured's Name*
First Last

Should match name(s) on deed.
Phone Number
Insured's Email
Address*
Street Address Address Line 2 City State ZIP Code
Highest Education Completed*
- High School
- Associate's Degree
- Bachelor's Degree
- Law or Medical Degree
Insured SSN*
DOB*
Martial Status*
- Single
- Married
- Divorced
Occupation*
Have you moved in the last 3 years?*
- Yes
- No
Please enter previous address*
Add Co-Applicant?*
- Yes
- No
Co-Applicant
Insured's Name*
First Last
Highest Education Completed*
- High School
- Associate's Degree
- Bachelor's Degree
- Law or Medical Degree
Insured SSN*
DOB*
Occupation*

Insured Amounts
Dwelling Amount:*
Water Backup Limit*
Sump pump?*
- Yes
- No
Back up system?*
- Yes
- No
Identify the system*
- Gas powered
- Water powered
- Battery powered
- Whole house generator
Liability Limit*
Deductible*
Jewelry/Furs/Fine Arts/Etc*
Medical Payments*

Property Information
Year Built*
Purchase Date*
Month
Day
Year
Purchase Price*
Number of Stories*
Square Footage*
Architecture Style*
- Ranch
- Colonial
- Split Level
Number of Bathrooms*
Number of Families*
- 1
- 2
- 3
- 4
Heat Type*
- Gas
- Radiator
If heat type is "other", please describe
Exterior Type*
- Frame
- Aluminum/Vinyl
- Masonry
- Masonry Veneer
- Stucco
Roof Type*
- Asphalt Shingle
- Tile / Slate
- Wood Shingle
- Tar & Gravel
- Composition
Roof Design*
- Gable
- Flat
- HIP
- Shed
- Mansard
- Gambrel
Foundation Type*
- Basement Unfinished
- Basement Finished
- Crawl Space
- Slab
Is there a Fireplace?*
- No
- Yes
How Many Fireplaces?
Wood or Gas Fireplace?

Please indicate if the property has any of the following below
Monitored Alarms*
(If issued, you must provide alarm certificate)
Garage*
- None
- Attached
- Detached
Garage*
- 1 Car
- 2 Car
- 3 Car
- 4 Car
Deck?*
- No
- Yes
Square Footage of Deck?
Porch*
- No
- Yes
Square Footage of Porch
Is the Porch open or enclosed
- Open
- Enclosed
Does the Insured have any dogs?*
- No
- Yes
How many dogs?
Breed Type
Is the Property currently in Foreclosure?*
- No
- Yes
Is the Property currently for sale?*
- No
- Yes
Please select any Add-Ons the property has
- Inground Swimming Pool
- Aboveground Swimming Pool
- Diving board
- Pool slide
- Hot Tub
- Trampoline
- Fire Extingusher(s)
- Wood Stove
- Dead Bolt
- Fenced-in Yard
Electric / Locked Cover For Inground Pool?*
- No
- Yes
Is the pool fenced?*
- No
- Yes
Height Of Pool Fence*
Does trampoline have enclosure net?*
- No
- Yes
Is there a business in the home?*
- No
- Yes
Type of Business

Is the Property more than 15 years old? If so, the following utility updates must be completed. Indicate the last year updated, below.
Furnace*
Electrical*
Plumbing*
Roof*
Please select:*
- Breakers
- Fuses
Any Homeowner claims in the past 5 years?*
Please explain*
Please provide details such as the date, the type of loss, and the amount paid.

Mortgage
Current Mortgage Company
Mortgagee Bill?*
- Yes
- No
Mortgage Company Name*
Current Carrier*
Number of years with Carrier*
Expiration Date*
MM slash DD slash YYYY
Premium*
Has coverage been cancelled or non-renewed in the last 3 years?
Please provide reason for coverage being cancelled or non-renewed*
Please enter any additional information you may have regarding this quote
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Contact Info

54 West Seegers Road
Arlington Heights, IL 60005

Phone: 847.427.8000

Fax: 847.640.8011

Email: info@midwestga.com

Web: www.Mibsga.com

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