Business Financial Statement 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?

Business Financial Statement

Note: Please complete this form in its entirety, completing the first section and each additional section that applies. This form is meant to be a tool to assess your client’s financial position as it applies to their insurability. Carrier financial supplements may still be required. Please refer to our financial underwriting guidelines. If your situation falls outside of these guidelines, please contact us.

When was the business established?

If multiple, interrelated businesses exist, please note details at the end of this form. Please include a copy of the most recent Profit & Loss/Income Statement to provide the best advice possible.

Profit & Loss/Income Statement

Click or drag files to this area to upload. You can upload up to 10 files.

The proposed insured is an:

Employee
Owner

List amount of business insurance in force and applied for in all companies on each officer or member of the business.

Name

Age

Ownership %

In force Amount

Am’t Applied For

Name

Age

Ownership %

In force Amount

Am’t Applied For

Name

Age

Ownership %

In force Amount

Am’t Applied For

Name

Age

Ownership %

In force Amount

Am’t Applied For

Name

Age

Ownership %

In force Amount

Am’t Applied For

Purpose (Please check all that apply):

Buy-Sell Arrangement
Key Person
Business Loan Collateral

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

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

Please provide additional details about the proposed insured(s) that might help us understand the financial history.

Save and Resume Later

Business Financial Statement Underwriting Questionnaire

Business Financial Statement

List amount of business insurance in force and applied for in all companies on each officer or member of the business.

Buy-Sell Arrangement

Key Person

Business Loan Collateral