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Rheumatoid/Juvenile/Psoriatic Arthritis 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:

Rheumatoid/Juvenile/Psoriatic Arthritis

Date of diagnosis:

Type of Arthritis:

Which joints have been involved?

Has the condition ever completely disappeared?

When did it disappear?

Has it relapsed?

Please indicate the dates the condition disappeared and reappeared. Also, please indicate if there are any known variables that trigger the onset of the condition or lead to remission (such as change in climate, location, etc.).

Does the proposed insured take any medications (prescription or otherwise) at this time?

Includes medications that were/are being used to control the arthritic condition or any other condition affecting the proposed insured

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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