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Depression/Anxiety/PTSD Underwriting Questionnaire
Please enable JavaScript in your browser to complete this form.
Agent's Name:
*
First
Last
Agent's Phone Number:
*
Agent's Email:
*
State of Issue/Delivery:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
*
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1922
1921
1920
Age:
*
Height:
*
Weight:
*
Ever a marijuana/THC user?
*
Yes
No
Current marijuana/THC user?
*
Yes
No
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?
*
Yes
No
Current cigarette smoker?
*
Yes
No
Date last used:
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
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29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
1995
1994
1993
1992
1991
1990
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1981
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1951
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.)
*
Yes
No
Please provide details for any other tobacco use:
Last date any form of tobacco was used:
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Is this case being premium financed?
*
Yes
No
Do you have a lender?
*
Yes
No
Insurance Type:
*
Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product
Face Amount:
*
Are there multiple policies/face amounts?
Yes
No
Face Amount:
Are you requesting any riders?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
Date(s):
Has the proposed insured been treated with any other treatment other than medication?
Yes
No
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:
Submit