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Sleep Apnea 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:

Sleep Apnea

Date of diagnosis:

Diagnosed as:

Obstructive
Central
Mixed
Unknown

Severity:

Mild
Moderate
Severe

Has an overnight sleep study been done?

Please provide sleep index below:

AHI

RDI

Lowest oxygen saturation percentage:

How is the sleep apnea being treated:

No treatment
Medication
Weight Loss
CPAP Mask
Surgery (UPPP)
Surgery (tracheotomy)
Other:

Please describe:

Is oxygen being delivered through/connected to the CPAP machine other than room oxygen? (Oxygen tank or Concentrator?)

If yes, automatic decline. For more information, please contact DBS Underwriting at underwriting@dbs-lifemark.com. or 952.697.5000 x202.

What is the current sleep index (AHI) with treatment?

What is the current sleep index (RDI) with treatment?

Does the proposed insured have any of the following:

Overweight
Arrhythmia
Coronary Artery Disease
Stroke
Depression
Lung Disease

Overweight - Please provide details:

Arrhythmia - Please provide details:

Coronary Artery Disease - Please provide details:

Stroke - Please provide details:

Depression - Please provide details:

Lung Disease - Please provide details:

Does the proposed insured use alcohol?

Please describe usage:

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, including any factors that may be relevant to assessment of the insurability of this individual.

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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.

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