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Business Financial Statement Underwriting Questionnaire

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

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 the accompanying pages for our financial underwriting guidelines. If your situation falls outside of these guidelines, please contact Terri Getman, JD, CLU, ChFC, RICP, AEP (Distinguished) at x230.

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.

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

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

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Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

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