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Motor Vehicle/DUI 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:

Motor Vehicle/DUI

Is the proposed insured employed?

Occupation:

Any DUI/DWI violations?

Provide date(s):

Penalty imposed? (e.g. jail, probation, mandated classes, license suspension, etc.)

Did the proposed insured spend time in jail?

Length of jail time:

Release date:

Is the proposed currently on probation?

When will probation end?

Any history of alcohol abuse or an advisement by a physician or other person to cut back or abstain from drinking?

Provide full details (e.g. how often and how much, any inpatient or outpatient treatment with dates, attending AA, etc.)

Does the proposed currently use alcohol?

How much per sitting?

How often?

Any history of recreational drug use?

What type(s)?

Date of last use:

In the last 5 years has the proposed insured had any speeding tickets?

Provide date(s) and indicate how many MPH over the limit for each incident:

If applicable, list any other motor vehicle violations with dates in the last 5 years:

Is the proposed insured’s driver’s license currently valid?

Has the proposed insured’s driver’s license ever been suspended?

Please provide reason(s), date of suspension(s), and date(s) of restoration:

Is the proposed insured’s driver’s license currently suspended?

When will it be restored?

Please provide any applicable information about the proposed insured that may help us understand the full history:

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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Diversified Brokerage Services, Inc.

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.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/