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Foreign National (Living inside the US) 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:

Foreign National (Living inside the US)

Are you a U.S. Citizen?

Please provide details of citizenship:

Please provide type of visa you currently hold (if green card, please note that as well):

City and Country of Origin:

Are you living in the United States?

How long have you lived in the United States?

Reason(s) for choosing a U.S.-based insurer:

Annual Income:

Do you own any U.S. Assets ?

Please List (if a home please indicate that as well):

Location of owned home:

Approximate Value of U.S. Assets:

Location of primary care physician:

Will medical records be available in English?

Please indicate details (translation services vary by carrier, and may or may not be available):

If applicable, will you cover translation service expenses?

TRAVEL: PRIOR 12 MONTHS (Please list all travel – international and country of residence)

Please list the following information: City/Country, Reason, Number of Trips/Dates, Total Days

For more than one trip, please separate your answers by hitting the "enter" key.

PLANNED TRAVEL: NEXT 12 MONTHS (Please list all travel – international and country of residence)

Please list the following information: City/Country, Reason, Number of Trips/Dates, Total Days

For more than one trip, please separate your answers by hitting the "enter" key.

Employment information (job title and brief description, including type of company you work for):

Are you married?

Is your spouse a U.S. Citizen?

Do you have children?

Please list ages of your children:

Location of immediate relatives with U.S. Citizenship or Green Card living in the U.S.:

Purpose of the U.S. Life Insurance (estate planning, income replacement, etc.):

Who will be the named beneficiary(s) of the life insurance policy (trust, spouse, children, etc.)?

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:

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
Fax 952.697.5001

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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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