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Epilepsy/Seizure Disorder 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:

Epilepsy/Seizure Disorder

Date of diagnosis: *

Date of last seizure: *

What type of Epilepsy or Seizure has been diagnosed?

Generalized Epilepsy
Partial (Focal) Epilepsy

Generalized Epilepsy: Choose as many as applicable below

Absence (Petite Mal) Seizures
Tonic Clonic (Grand Mal) Seizures
Myoclonic Seizures
Febrile (associated with fever) Seizures
Tonic Seizures
Atonic Seizures
Nocturnal Seizures
Reflex Seizures (television Epilepsy)

Partial (Focal) Epilepsy: Choose as many as applicable below

Simple Partial Seizures (Jacksonian)
Complex Partial Seizures (includes temporal lobe)
Partial Seizures
Other

Other (Describe):

What type of symptoms accompany the epileptic episodes? *

Unconsciousness
“Clouded Consciousness”
Uncontrolled twitching movements
Deep sleep

How frequent are the epileptic episodes? *

One episode only
Several episodes but clustered in a very short period of time and none since that time
6 or less per year
7-12 per year
13 or more per year

Per Month: *

13 or more per year

Per Week: *

13 or more per year

Per Day: *

13 or more per year

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

Include medications that are used to control the condition

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 any surgical procedure been recommended/done to treat the Epileptic condition?

Date of surgery

Surgery details:

Personality or mentality changes?

Please describe:

Personality or mentality changes?

History of alcohol misuse?

Please describe:

History of alcohol misuse?

Compliant with recommended treatment?

Please describe:

Compliant with recommended treatment?

Does the proposed insured drive a car?

Please describe:

Does the proposed insured drive a car?

Is there any history of motor vehicle accidents?

Please describe:

Is there any history of motor vehicle accidents?

Does the proposed insured engage in any hazardous activities including aviation or scuba diving?

Please describe:

Does the proposed insured engage in any hazardous activities including aviation or scuba diving?

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

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