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Testicular Cancer 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:

Testicular Cancer

Date of diagnosis: *

Date of surgery: *

Please include a copy of the pathology report or any other medical reports

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Exact name of the type of tumor: *

Gonadal Stromal Tumor
Secondary Testicular Tumor

What was the type of testicular cancer? *

Seminoma
Non-Seminomatous
Non germ cell/stromal
Sarcoma

Indicate the stage of the cancer: *

Stage 1
Stage 2
Stage 3

Indicate the grade of the cancer:

Primary Tumor (“T”) *

Lymph Node (“N”) *

N0
N1
N2
N3 or more

Metastasis/spread (“M”) *

Has there been any other treatment? (Check all that apply)

Radiation Therapy
Chemotherapy
Other

Other:

Has there been any evidence of recurrence? *

Please provide details: *

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 any additional details about the proposed insured’s medical condition:

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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 Simplicity Investments, Inc. Member FINRA/SIPC. 475 Springfield Ave, Summit, NJ 07901 (303) 797-9080. DBS is not affiliated with Simplicity Investments.

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