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Foreign National (Living inside the US) Underwriting Questionnaire
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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
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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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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
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8
9
10
11
12
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DD
1
2
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YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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1940
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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:
Foreign National (Living inside the US)
Are you a U.S. Citizen?
Yes
No
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?
Yes
No
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 ?
Yes
No
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?
Yes
No
Please indicate details (translation services vary by carrier, and may or may not be available):
If applicable, will you cover translation service expenses?
Yes
No
TRAVEL: PRIOR 12 MONTHS (Please list all travel – international and country of residence)
City/Country
Reason
Number of Trips/Dates
Total Days
PLANNED TRAVEL: NEXT 12 MONTHS (Please list all travel – international and country of residence)
City/Country
Reason
Number of Trips/Dates
Total Days
Employment information (job title and brief description, including type of company you work for):
Are you married?
Yes
No
Is your spouse a U.S. Citizen?
Do you have children?
Yes
No
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?
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:
Please provide additional details about the proposed insured’s medical history:
Submit
