Underwriting Questionnaire

Complete our fast and easy underwriting questionnaire to receive a preliminary offer in 48-hours or less.
Agent Information  * Denotes Required Field
Agent:*
Association:
Phone:*
Fax:*
Email:*
Client Information
Client Name:
Date of Birth:*
State of Residence:
Occupation:
Sex:* Male Female
Height:*
Weight :* lbs.
Occasional Tobacco User:*
Insurance Amount:*
Premium Tolerance:
(Amount prospect can afford to spend monthly)
Plan of Insurance:
Additional Insured's Name
 (only if applying for Survivor UL)
Other Companies Actions
Company:
Action:
Date:
 
 
 

Click the box next to the impairment(s) below which most closely apply to your client. After selecting the impairment(s) select NEXT to go to questions that will help us provide the most accurate offer. Remember, you may choose multiple impairments.

Alzheimer's Disease Asthma Cancer Chronic Bronchitis
COPD Coronary Artery Disease Crohn's Disease Depression
Diabetes Driving Drug/Alcohol Emphysema
Epilepsy Gastric/Peptic Ulcers Heart Disease Hepatitis C
Kidney Disease Liver Disease Multiple Sclerosis Obesity
Parkinson's Disease Rheumatoid Arthritis Sleep Apnea Stroke
Tobacco Ulcerative Colitis or Ileitis Vascular Disease Other

The information that you are filling out on this page does not AUTO SAVE…
If you click 'next' and then need to come back to this page, you will need to re-enter the information.