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Foreign Travel Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

Proposed Insured's Name: *

First

Last

Sex: *

Male
Female

What is the proposed insured's: *

Date of Birth
Age

Please select "age" if the date of birth is unknown.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

Foreign Travel

Client Occupation:

Employer:

Location of work:

Annual Income:

Main Duties:

Citizenship:

Country of origin:

US Visa type:

Expiration:

Current Residence Location:

Primary Residence Location:

Location of primary care physician:

Travel: Prior 12 Months (Please list all travel)

Please list the following information: City/Country, Reason, Number of Trips/Dates, Total Days

For more than one trip, please separate your answers by hitting the "enter" key.

Planned Travel: Next 12 Months (Please list all travel)

Please list the following information: City/Country, Reason, Number of Trips/Dates, Total Days

For more than one trip, please separate your answers by hitting the "enter" key.

Does the proposed expect to visit any non-urban areas?

Likely accommodations (hotel, house, camping, etc.):

Proximity to medical facilities?

Travel arrangements (light aircraft, boat, etc.):

Does the proposed insured take any medications (prescription or otherwise) at this time?

Medication 1:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 2:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 3:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 4:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 5:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

More than five medications?

Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:

Please provide additional details about the proposed insured’s medical history:

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Minneapolis, MN 55416
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Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/