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The purpose of this form is to authorize Massachusetts Mutual Life Insurance Company (“MassMutual”) to
release information, including non-public personal health and financial information, about the Proposed Insured (also referred to as “I” or “me” or “my”) to the Agent or Broker who submitted an application to MassMutual on my behalf and/or the General Agency with whom the Agent or Broker is contracted (collectively the “Agent/ Broker/Agency”) and to be used as described on the PDF.

Review the following sources so you can set expectations with your clients during the application process.

If applying for DI discounts or consolidated employer billing for DI only, complete form F6749. Eligibility for Life: (1) Individual policies that are part of a Qualified Plan; (2) a minimum of three policies; or (3) an annual premium of at least $10,000.