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

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? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

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:

Life with LTC/CI type rider
Asset based life/LTC hybrid product

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

Tier 1 - Disqualifying Conditions: Please indicate if the proposed insured has any of the following conditions:

Type 1 Diabetes
Dialysis treatment or chronic kidney disease
Oxygen use for any reason
Parkinson’s disease, Multiple Sclerosis, or muscular dystrophy
Use of any narcotic drug or prescription pain medication currently or within the last 3 months (dental work excluded)
Alzheimer’s disease, dementia, or taking medication for memory loss

Tier 3: Postponement Conditions - Please indicate if any of the following is true

Received any join injections with a cortisone or other steroid medication in the past 6 months
Is currently receiving or scheduled for physical therapy or receiving more than twice monthly maintenance chiropractic care
Has surgery scheduled in the next 6 months, or has been advised to have surgery that is not yet completed
Is currently being evaluated for an undiagnosed medical condition

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:

Cancer*
Diabetes
Heart or CAD

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?

Parents
Siblings

Select all that apply

Are you currently or have you taken any medications within the last two years?

Are you employed?

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:

Save and Resume Later

If the proposed insured:	Wait to submit the application until:
Received any join injections with a cortisone or other steroid medication in the past 6 months	6-12 months (depending on reason for injection and if there were multiple injections – discuss with a DBS Underwriter)

If the proposed insured:	Wait to submit the application until:
Is currently receiving or scheduled for physical therapy or receiving more than twice monthly maintenance chiropractic care	At least 30 days after the date of your last physical therapy treatment and you have been released from care (you must be back to 100% activity without limitations)

If the proposed insured:	Wait to submit the application until:
Has surgery scheduled in the next 6 months, or has been advised to have surgery that is not yet completed	At least 3 months post-operative, fully recovered, back to 100% activity and released from all medical and doctor’s care

If the proposed insured:	Wait to submit the application until:
Is currently being evaluated for an undiagnosed medical condition	Until all evaluations have been completed and a diagnosis has been made

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

Section 1 - Disqualifying Conditions

If you selected any of the preceding, the proposed insured WILL NOT qualify; please do not proceed.

If you selected any of the preceding, the proposed insured MAY qualify; please proceed.

If you selected any of the preceding, please proceed, using the specific guidelines listed above.

Section 2 - To be Completed After the Prequalifying Conditions Have Been Met in Section 1

Section 3 - Medication Prequalification

Section 4 - General Health Questions to Accompany LTC/Chronic Illness Rider Questionnaire

For further quoting, please complete the current questionnaire. After submission, you will receive a link to our cancer questionnaires.

For further quoting, please complete the current questionnaire. After submission, you will receive a link to our hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract questionnaires.

In the last 5 years…

For further quoting, please complete the current questionnaire. After submission, you will receive a link to our aviation questionnaires. Please note: All aviation activity is summitted to our carriers for review.