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Depression/Anxiety/PTSD 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.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

Depression/Anxiety/PTSD

Date of initial and subsequent episodes of depression:

What specific type(s) of depression has/have been diagnosed?

PTSD
Bipolar Disorder (mixed)
Dysthymia
Anxiety
Bipolar Disorder (manic)
Major depression
Situational depression
Bipolar Disorder (depressed)
Other

Other (Describe):

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

Medication 1:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 2:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 3:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 4:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 5:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

More than five medications?

Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:

Has dosage or medication changed in the last year?

Please describe medication and dosage taken previously:

Has the proposed insured ever been hospitalized or gone to the Emergency Room for any depression/anxiety symptoms?

Date(s):

Has the proposed insured been treated with any other treatment other than medication?

Select all that apply:

Counseling/Therapy
Treatment
Other

Date of last treatment:

Other (Describe):

Has the proposed insured had (or been diagnosed with) any of the following conditions:

Alcohol/Drug abuse
Anorexia/Bulimia nervosa
Personality/Psychotic disorder
Suicidal thoughts/attempts

Date of last use:

Alcohol/Drug abuse

Date diagnosed:

Anorexia/Bulimia nervosa

Remission date:

Anorexia/Bulimia nervosa

Date diagnosed:

Personality/Psychotic disorder

Exact name of condition:

Personality/Psychotic disorder

Date of last such thought/attempt:

Suicidal thoughts/attempts

The proposed insured is:

Currently working
On disability
Other/Retired

Other/Retired (Explain):

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

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5501 Excelsior Blvd
Minneapolis, MN 55416
Phone 800.869.1DBS / 952.697.5000
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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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