New Loan Request - The Money Multiplier

Getting Started With Your Loan Request
Please select the company that you currently have a policy with.
Which company do you currently wish to request a loan from?*
- American United Life / One America
- The Ohio National Life Insurance Company
- Penn Mutual
- Security Mutual Life Insurance Company of New York
- Ameritas Life Insurance Corp.
- Lafayette Insurance Company
- Mass Mutual
Before you continue, please note that you'll need a voided check at the end of the form to complete the loan request. If you don't have this yet, take a picture with your phone or scan it into your computer so you can easily upload it.

Policy Information
Owner Name*
*This name HAS to be the owners name- even if the owner is a business.
First Last
Insured Name*
This is the name of the person that is insured under your policy.
First Last
Email*
Policy Owner SSN, EIN or TIN*
Today's Date*
Date Format: MM slash DD slash YYYY

Policy Owner Information
Policy Owner Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Owner Phone Number*
Who is your Mapping Specialist?*

Policy Information
AUL Policy Number(s):*
*Only list policy numbers with the same ownership as listed above. *Starts with a "0" and will be 10 numbers long.
Policy Number for Ameritas*
*Only list policy numbers with the same ownership as listed above. *Starts with a "L" and will be 8 numbers long followed by a letter.
Policy Number for Ohio National*
Should be 7 numbers.
Policy Number for Security Mutual Life*
Should be 7-9 numbers starting with "00"
Policy Number for Penn Mutual*
Should be 7 or 8 numbers.
Policy Number for Lafayette Insurance*
Policy Number for Mass Mutual*

Loan Amount
Please let us know how much you want the loan to be for. *Most people just select maximum loan amount!
Request for Policy Loan Amount
- Maximum Loan Value
Loan Amount (If different than maximum)*
Please enter a number from 100 to 1000000.

Location Information
For some states, there are extra requirements. Please let us know if you are in these special areas.
Do you live in (AZ, CA, ID, LA, NM, NV, TX, WA, WI)*
- Yes
- No
Marital Status*
- I am married (spouse’s signature required below)
- I am not married
Spouse Name*
First Last

Where will you be signing this document?
We need to know where you'll be when you sign this document for legal purposes.
Current location*
Street Address Address Line 2 City State ZIP Code

Please enter the current location you'll be in when you sign this document.

Getting Started With Your Loan Request