Underwriting Questionnaire - Please Complete All Fields
Agent Information
* Agent:* Phone:
Address:* Fax:
* Email:

Client Information
* First Name:* Last Name:
Date of Birth://* Sex:Male Female
Does Your Client Use Tobacco:Yes No
* Insurance Amount:
Height: Weight (lb):
Plan of Insurance:Term UL SUL
Additional Insured's Name(only if applying for Survivor UL)

Other Companies Actions
Company:Action:Date:
mm yy
mm yy
mm yy

Click the box next to the impairment(s) below which most closely apply to your client. After selecting the impairment(s) please complete the questions below. This will help us provide the most accurate offer. Remember, you may choose multiple impairments.
Stroke
Tobacco
Sleep Apnea
Heart Disease
 Diabetes
Driving
Drug/Alcohol
Hepatitis C
 Depression
Cancer
Obesity
Other

         

Source Brokerage, Inc. (800)543-7167
Questions? Contact Jeff Darnell at ext. 225.

For Licensed Insurance Agent's Use Only. Not For Use With The General Public.