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Multiple Sclerosis 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:

Multiple Sclerosis

Date of first diagnosis: *

Type of multiple sclerosis

Relapsing-remitting
Progressive
Benign (No signs or symptoms for 5+ years)

Please indicate how the condition was diagnosed:

MRI
Evoked Potentials
Other

Other (Describe):

Approximate date of Attack(s)

Duration of Attack(s)

Residual Effects

None
Minimal
Moderate
Severe

Specify Impairment for Residual Effects

Approximate date of Attack(s)

Duration of Attack(s)

Residual Effects

None
Minimal
Moderate
Severe

Specify Impairment for Residual Effects

Approximate date of Attack(s)

Duration of Attack(s)

Residual Effects

None
Minimal
Moderate
Severe

Specify Impairment for Residual Effects

Approximate date of Attack(s)

Duration of Attack(s)

Residual Effects

None
Minimal
Moderate
Severe

Specify Impairment for Residual Effects

If more than four, please list: Approximate date of attack(s), Duration of attack(s), Residual effects, Specify impairment for residual effects

Is there a disability?

Please provide an EDSS score or a description

EDSS Score

Description

Work status

Currently working
On Disability

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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