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Asset-Based or With Long-Term Care/Chronic Illness Rider Underwriting Questionnaire

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

Asset-Based or With Long-Term Care/Chronic Illness Rider

Please note:

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

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.

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.

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:
Select all that apply

In the last 5 years…

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