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Quick Fact-Finder
All personal information protected by HIPAA regulations (see HIPAA Form attached with supplemental forms)
Completion of a FACT FINDER will accelerate the underwriting process
Agent Name
First
Last
Agent Phone Number
Email
Proposed Insured’s Legal Name
First
Last
Date of Birth
MM slash DD slash YYYY
Plan of Insurance Requested
Term
UL
WL
SUL
DI
LTCi
Client’s Budget
Rate Class Desired
Best Rate
Preferred
Standard
Rated
Rated:
Present Nicotine Use
NONE
Cigarettes
Cigars
Dip
Chew
Nicotine Gum
Other
Frequency of Use Per Day
Other
Quantity Per Month
Former Tobacco Use (List each type of tobacco, quantity and frequency used, and date of last use)
Height
Weight (pounds)
Family History (Family history is a consideration for each rate class)
To your knowledge, is there any family history (parent or siblings) with onset of disease prior to age 60 due to cardiovascular disease, cerebrovascular disease, diabetes, or cancer?
Yes
No
Provide full details with impairment, age at onset, and age at death if deceased
Father
Mother
Siblings
Father - Provide full details with impairment, age at onset, and age at death if deceased
Mother - Provide full details with impairment, age at onset, and age at death if deceased
Sibling - Provide full details with impairment, age at onset, and age at death if deceased
Blood Pressure and Cholesterol
Latest BP Reading
Latest Total Cholesterol
Latest Cholesterol/HDL Ratio
Are you currently taking any medication for blood pressure?
Yes
No
Name of Medication
Are you currently taking any medication to lower cholesterol?
Yes
No
Name of Medication
Aviation/Avocation
In the past 5 years have you or do you intend to participate in any of the activities listed?
None
Flying
Racing
Sky diving
Scuba diving
Other
Other
Details
Citizenship/Residency/Travel
US Citizen
Yes
No
Provide type and expiration date of visa, green card status, and length of time in USA
Any future plans to live or travel outside the USA? *check with your Brokerage General Agency regarding state compliance prior to completing any application(s)
Yes
No
Provide purpose, cities, countries, frequency, and duration
Driving History
Have you had any of the following motor-vehicle-related incidents in the past 10 years?
None
Moving Violation
Reckless Driving
DWI or DUI
License Suspension
License Revoked
Provide dates, details
Medical History
Have you ever had, been told you had, or been treated for any of the conditions listed?
Alcohol abuse
Alzheimer’s/dementia/cognitive impairment
Asthma
Cancer
Cirrhosis
COPD
Coronary artery or cerebrovascular disease
Crohn’s disease
Depression/anxiety
Diabetes
Drug abuse
Epilepsy
Heart murmur/valve disease
Hepatitis
Irregular heartbeat/palpitations
Kidney disease
Lupus
Multiple sclerosis
Peripheral vascular disease
Rheumatoid arthritis
Sleep apnea
Stroke
Other
Other
List dates, diagnosis, details, treatment, and any additional medications (Refer to Common Medical and Non-Medical Impairment sections for critical underwriting factors)
Comments
This field is for validation purposes and should be left unchanged.
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