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Personal Financial Statement 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:

Personal Financial Statement

Note: Please complete this form in its entirety, completing the first section and each additional section that applies. This form is meant to be a tool to assess your client’s financial position as it applies to their insurability. Carrier financial supplements may still be required. Please refer to our financial underwriting guidelines. If your situation falls outside of these guidelines, please contact us.

Please check any dependents relying on financial support from Proposed Insured:

Spouse
Minor Children

Is spouse employed?

Spouse’s Gross Income:

Number of Children:

Purpose of insurance (check all that apply):

Survivor Income
Debt Liquidation
College Funding
Estate/Tax Liquidity
Income Tax Liquidity
Charitable Giving
Other

Other (Explain):

1st Proposed Insured: Current Annual Household Income

Gross Compensation (e.g. Salary, Commissions, Bonuses, etc.):

Other Income (e.g. Dividends, Interest, Net Real Estate Income, etc.):

Total Annual Cash Income before taxes:

1st Proposed Insured: Net Worth (excluding any business interest)

Liquid Assets (assets that can be easily changed to cash):

Other assets:

Liabilities:

Net Worth (excluding business):

1st Proposed Insured: Business Value

Business Value:

Is there a second proposed insured?

2nd Proposed Insured: Current Annual Household Income

Gross Compensation (e.g. Salary, Commissions, Bonuses, etc.):

Other Income (e.g. Dividends, Interest, Net Real Estate Income, etc.):

Total Annual Cash Income before taxes:

2nd Proposed Insured: Net Worth (excluding any business interest)

Liquid Assets (assets that can be easily changed to cash):

Other assets:

Liabilities:

Net Worth (excluding business):

2nd Proposed Insured: Business Value

Business Value:

Does the proposed insured have a personal accountant/CPA?

Have either the proposed insured (s) or owner filed for bankruptcy within the past five years?

Please provide details including whether the bankruptcy was dismissed or discharged; type of bankruptcy (chapter); whether it was personal or business related; current status; single or multiple occurrences; any outstanding judgments, liens or garnishments, etc.

Please provide additional details about the proposed insured(s) that might help us understand the financial 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
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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/