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Mature Age Lifestyle 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:

Mature Age Lifestyle

Note: The purpose is to help the DBS Underwriting Team get to know the proposed insured beyond what is written in medical records or what is on the medical exam. This list of questions will help us better position your case. Please elaborate as much as possible.

Does the proposed insured have regular, routine full physical exams? (Every 12-18 mos.) *

Please explain:

Does the proposed insured participate in any type of exercise routine? *

Please provide details:

Does the proposed insured use any assistive devices? (cane, walker, etc.) *

Please provide details:

Is there a history of falling by the proposed insured? *

Date(s):

Please provide details:

Does the proposed insured drive? *

Please provide details:

Does the proposed insured manage his/her own financial affairs/investments? *

Please provide details:

Is the proposed insured employed? *

Please provide details:

Is the proposed insured involved in any volunteer or charity work? *

Please provide details:

Please describe the proposed insured’s hobbies and leisure time activities:

What does owning an insurance policy mean to the proposed insured and/or what is the ultimate purpose for this policy?

What other factors will enable us to favorably present the application to the insurance company underwriters?

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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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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