Policy Assessment Client Worksheet

800.869.1DBS

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Policy Assessment Client Worksheet

If you have questions, please email insurance@dbs-lifemark.com or call:

Barbara Frederickson: 877.593.7690

Jim Boldischar: 877.593.7655

All completed forms are submitted via our secure server so you can be assured that your information is safe with us.

Name of Advisor you are working with:
First Last
Is this a joint case?*
- Yes
- No
If yes, please answer all questions for Client #2
Policy Objectives
- Increase Guarantee(s)
- Reduce Annual Premium
- Increase Face Amount
- Reduce Years to Pay
- Life with LTC Rider
- Other
Please describe:
Client #1 Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
State*
State
Gender:*
- Male
- Female
Height*
ft. in.
Weight*
lbs.
Have you ever used nicotine products?*
- Yes
- No
What type of nicotine products?*
Cigarette, cigar, pipe, snuff/chew, patch, gum, e-cigarette, vape
Date of last use:*
MM slash DD slash YYYY
Client #1 Health Information
Have you ever been treated for any of the following conditions? (Check all that apply):*
- Cancer
- Diabetes
- Heart Disease
- Kidney/Liver Disease
- Vascular Disease
- Other:
- None of the above
Type of cancer*
Other:
Client #1 Medications
Is the client currently taking any medications?*
- Yes
- No
Medication #1*
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)*
Medication #2
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)
Medication #3
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)
Client #1 Doctor Information
Doctor's Name*
First Last
Doctor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of last visit*
MM slash DD slash YYYY
Reason for visit*
Client #2 Information
Name
First Last
Date of Birth
MM slash DD slash YYYY
State
State
Gender:
- Male
- Female
Height
ft. in.
Weight
lbs.
Have you ever used nicotine products?
- Yes
- No
What type of nicotine products?
Cigarette, cigar, pipe, snuff/chew, patch, gum, e-cigarette, vape
Date of last use:
MM slash DD slash YYYY
Client #2 Health Information
Have you ever been treated for any of the following conditions? (Check all that apply):
- Cancer
- Diabetes
- Heart Disease
- Kidney/Liver Disease
- Vascular Disease
- Other:
- None of the above
Type of cancer
Other:
Client #2 Medications
Is the client currently taking any medications?*
- Yes
- No
Medication #1
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)
Medication #2
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)
Medication #3
Medication Name (i.e. Asprin) Dosage (i.e. 81mg) Frequency (i.e. 1x Daily) Date Prescribed
Reason for Taking (i.e. Heart Maintenance)
Client #2 Doctor Information
Doctor's Name
First Last
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of last visit
MM slash DD slash YYYY
Reason for visit

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Policy Assessment Client Worksheet

Client #1 Information

Client #1 Health Information

Client #1 Medications

Client #1 Doctor Information

Client #2 Information

Client #2 Health Information

Client #2 Medications

Client #2 Doctor Information