Preliminary Inquiry

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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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FSA

4820 Six Forks Rd. Raleigh, NC 27609
Phone: 919.981.0333

Preliminary Inquiry

Client Information

Coverage Information

Medical Provider Information

Health History

General Questions

Agent Information

Print & Sign Health Authorization Form to Follow