Life Insurance Gift Interest Form Your Name(Required) First Last Preferred Name/TitlePreferred Name/ TitleMailing Address(Required) Street Address Address Line 2 City ZIP Code Preferred Method of ContactPreferred Method of ContactEmailPhoneMailNo PreferenceBest time to contact me(Required)Best time to contact meYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)My Interest(Required)Please check all that apply: I would like to learn more about naming MSV as a beneficiary of a life insurance policy. I have already named MSV as a beneficiary of a life insurance policy. I am considering a future gift to MSV through my will, trust, retirement account, or other estate plan. I would like MSV to share general information that I can provide to my financial, legal, insurance, or tax advisor. I would like someone from MSV to contact me for a confidential conversation. Gift Details, If Known(Required)Type of planned gift Life insurance policy Will or trust I am considering a future gift to MSV through my will, trust, retirement account, or other estate plan. Retirement account beneficiary designation Not sure yet Other Other:Gift designation preference(Required)Gift designation preference Greatest need/unrestricted support Advocacy and physician leadership Physician/clinician well-being Education and professional development MSV Foundation programs I would like to discuss options Other Other:Estimated future gift amount or percentage, if knownOptional; MSV understands this may change over time.Recognition Preferences(Required)Recognition Preferences MSV may recognize me publicly as a legacy supporter. I prefer to remain anonymous. Please contact me before listing my name in any recognition materials. Name as it should appear for recognition, if applicable:Name as it should appear for recognition, if applicable:Your Comments/QuestionsAcknowledgment(Required) Acknowledgment(Required)By submitting this form, I understand that this is not a legally binding commitment and that MSV does not provide legal, tax, financial, or estate planning advice. I understand that I should consult my attorney, financial advisor, insurance professional, or tax advisor before making decisions about my estate or beneficiary designations. Δ
