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Preliminary Inquiry
Client Information
Name of Insured :
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
State of Residence
*
Gender
*
Male
Female
Height
*
Weight
*
Tobacco Use
*
Yes
No
Has client used any form of tobacco in the last 3 years?
Please state type(s) of tobacco used, frequency and amount of use, when use began and/or how long since quitting
*
U.S. Citizen
*
Yes
No
Resident Status
Please provide details of residency (type of Visa, Green Card, etc) Country of Citizenship and how long in U.S.
Employed or Disabled?
*
Annual Income
*
Coverage Information
Face Amount
*
Policy Type
*
Term
Term w ROP
Universal Life
Guaranteed UL
Whole Life
Premium Mode
*
Annual
Semi Annual
Quarterly
Monthly
Single Premium
Other
Term Duration (# of years)
Total Insurance Currently Inforce
*
Indicate "none" if no insurance inforce
If this policy will replace any existing coverage, please indicate below & include 1035 Exchange amount, if any
Has Client Ever Been Declined for Insurance Coverage?
*
Yes
No
Give Date & Reason for Decline
*
Medical Provider Information
Do You Have a Primary Care Physician?
*
Yes
No
Date Last Consulted
*
MM slash DD slash YYYY
Does Client See Any Specialist?
*
Yes
No
Type of Specialist, Reason for Consultation, Treatments Prescribed
*
Health History
When providing details, please include date of diagnosis & provider who diagnosed and what treatments have or are currently being done
Cardiovascular Conditions
*
Heart Disease
Angina
Stroke
High Blood Pressure
None
Please check all that apply
Details of Cardiovascular Condition(s)
*
Cancer History
*
Yes
No
Type, date of diagnosis, stage of cancer, grade, type of treatment(s), outcome of treatment, date and outcome of last scan. Date of any currently scheduled scans.
*
Diabetes
*
Type I
Type II
None
Age at Diagnosis
*
Current A1-C Level
*
Current Treatments for Diabetes
*
Substance Use
*
Alcohol
Marijuana
Recreational "Street" Drugs
Any Drug Not Prescribed by a Physician
None
Check all that apply to client's current use or history of use
Details of Substance Use/Abuse
*
Please state type(s) substance used, frequency and amount of use, when use began and/or how long since quitting. Indicate if client has been advised to have or has had treatment for ABUSE of any substance, including treatment dates
List of Medications or Other Conditions Not Listed Above
*
Please list all medications that are currently being prescribed, including the dosage information. Please include details of other diagnosis not covered above (or enter none)
General Questions
Bankruptcy (past 7 years)
*
Yes
No
Details of Banruptcy
Please indicate type of bankrutcy, causation, date of filing, date of discharge
Driving Record
*
DWI/DUI
Speeding Violations
Traffic Violations
None
Check all that apply
Details of Driving Record
*
List dates of violations and/or convictions
Private Aviation
Yes
No
If "yes", a seperate questionnaire will be needed in order to collect full details
Hazardous Avocations
Scuba Diving
Hang Gliding
Rock Climbing
Auto Racing
Other
Check all that apply. A seperate questionnaire will be needed to collect details on any avocation(s).
Travel or Residence Outside of U.S. or Canada
*
Yes
No
Details of Foreign Travel
Provide regions or destinations visited or resided, dates visited or resided and frequency /dates of future travel.
Agent Information
Name
*
First
Last
Email
*
Agent Is Licensed In:
Resident State of Insured
Resident State of Policy Owner (if other than insured)
Trust State (if a Trust is Owner or Beneficiary)
Print & Sign Health Authorization Form to Follow
When you click "Submit" below, you will be re-directed to the health information authorization form. Please provide a copy to your client and keep a signed copy on file.
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