Agent's Phone Number: * Agent's Email: * State of Issue/Delivery: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Send to Additional Email? Proposed Insured's Name: * What is the proposed insured's: *
Please select "age" if the date of birth is unknown.
Height: * Weight: * Ever a marijuana/THC user? * Ever a cigarette smoker? * Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) * Is this case being premium financed? * Face Amount: * Are there multiple policies/face amounts? Are you requesting any riders? Asset-Based or With Long-Term Care/Chronic Illness Rider Please choose the product:
Please complete the General Health Questionnaire found in Section 4 of this questionnaire. Additional information may be needed for the life insurance portion of the underwriting process.
Section 1 - Disqualifying Conditions Tier 1 - Disqualifying Conditions: Please indicate if the proposed insured has any of the following conditions: Tier 2 - Disqualifying Conditions: Please indicate if the proposed insured has any of the following conditions: Congestive heart failure Heart attack, heart or carotid artery surgery within the past six months Osteoporosis with a compression fracture or height loss of two or more inches Rheumatoid arthritis taking Prednisone or a biologic agent (Enbrel, Humira, Remicade, Rituxan, Kineret, Actemra, Orencia, Cimzia, etc.) Organ transplant recipient Currently collecting any type of disability payments Transient ischemic attack (TIA) within the past 6 months or two or more TIAs Moderate to severe emphysema or moderate to severe chronic obstructive pulmonary disease (COPD) Severe sleep apnea with no treatment Bipolar disorder, mania, recurrent major depression or schizophrenia Any medical condition that has restricted mobility or has impacted ADLs in any way Stroke within the past 12 months, multiple stroke history, or stroke with significant cardiac disease history BMI (body mass index) is less than 17 or greater than 42 Cardiomyopathy within the past 3 years History of falls due to gait disturbance or dizziness, or two or more falls in the last 36 months Use of a cane of any variety, 3 prong cane, walker or wheelchair currently or within the last 12 months Use of any medication on the medication decline list (See Section 3) Issuance of or requirement and use of a handicap parking permit due to physical limitations or medical conditions Cancer (See Section 2) Tier 3: Postponement Conditions - Please indicate if any of the following is true Section 2 - To be Completed After the Prequalifying Conditions Have Been Met in Section 1
Please list any specific diagnoses/medical conditions, hospitalizations, or surgeries of the proposed insured. Name of diagnosis Date Current Medications Treatments Please check for any of the following additional considerations: Section 3 - Medication Prequalification
Medications can indicate significant health problems that can be uninsurable. Please provide information on all medications taken and be sure the list is comprehensive as some medications alone could be the basis for disqualification. If helpful, please refer to each carrier’s medication disqualification list located on the DBS website on the Underwriting Questionnaires page.
Does the proposed insured take any medications (prescription or otherwise) at this time? Please provide any additional details about the proposed insured’s medical history that may be relevant: Section 4 - General Health Questions to Accompany LTC/Chronic Illness Rider Questionnaire
In the last 10 years, have you been treated for, or diagnosed with:
High blood pressure, heart attack, chest pain, heart murmur, irregular heartbeat, stroke, or any other disease or disorder of the heart or blood vessels? Cancer or a tumor, cyst or growth? Asthma, bronchitis, emphysema, tuberculosis or any other disease or disorder of the lungs or respiratory system? Seizure, paralysis, headaches, multiple sclerosis or any other disease or disorder of the brain or nervous system? Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder? Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract? Diabetes, borderline diabetes, sugar in the urine, thyroid disorder, or any other disease or disorder of the glandular system? Kidney stones, nephritis, any blood or protein in the urine, sexually transmitted disease, prostate disorder, breast disorder or any other disease or disorder of the urinary or reproductive system? Any disease or disorder of the bones, joints, or muscles? Have your parents or siblings died as a result of cancer, stroke, or heart disease prior to age 60?
Select all that apply
Are you currently or have you taken any medications within the last two years? Have you had any surgeries in the last 6 months or are there plans for surgery in the near future? In the last 5 years… Have you engaged in any of the following activities: private pilot, scuba/skin diving, organized motor vehicle racing (i.e. snowmobile or motorboat), skydiving, hang gliding, mountain climbing, or rodeo? Have you traveled outside the U.S. or Canada? Any future plans to travel abroad? Have you been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations? Have you been on parole or probation or convicted of a felony or misdemeanor? Have you regularly used, or are you currently using any controlled substance, excluding marijuana? Have you ever been medically advised to limit or discontinue the use of alcohol or drugs, or sought or received treatment? Do you exercise regularly? Please provide additional details about the proposed insured’s medical history: