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Urine Abnormalities/Proteinuria/Hematuria 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:

Urine Abnormalities/Proteinuria/Hematuria

Date of first diagnosis of urine abnormality:

Did your doctor diagnose a kidney disorder?

Please list:

Indicate the following laboratory findings, if previously (and recently) done by your physician (or attach recent urine readings/tests):

Upload recent urine readings/tests or any other medical reports

Click or drag files to this area to upload. You can upload up to 10 files.

Protein in the urine (proteinuria): Date of most recent tests

Protein in the urine (proteinuria): Results

Protein in the urine (proteinuria): Normal reference range

Blood in the urine (hematuria): Date of most recent tests

Blood in the urine (hematuria): Results

Blood in the urine (hematuria): Normal reference range

Blood urea nitrogen (BUN) level: Date of most recent tests

Blood urea nitrogen (BUN) level: Results

Blood urea nitrogen (BUN) level: Normal reference range

Creatinine level: Date of most recent tests

Creatinine level: Results

Creatinine level: Normal reference range

Is there any known family history relating to kidney/cardiovascular disease?

Family Member #1

Relation:

Age (if living):

History of kidney disease?

History of heart disease or circulatory disorder?

History of stroke?

Age at death:

Cause of Death:

Family Member #2

Relation:

Age (if living):

History of kidney disease?

History of heart disease or circulatory disorder?

History of stroke?

Age at death:

Cause of Death:

Family Member #3

Relation:

Age (if living):

History of kidney disease?

History of heart disease or circulatory disorder?

History of stroke?

Age at death:

Cause of Death:

Family Member #4

Relation:

Age (if living):

History of kidney disease?

History of heart disease or circulatory disorder?

History of stroke?

Age at death:

Cause of Death:

More than four family members with a history relating to kidney/cardiovascular disease?

Please list: Age (if living), History of kidney disease (yes or no), History of heart disease or circulatory disorder (yes or no), History of stroke (yes or no), Age at death, Cause of death

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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