Impaired Risk Insurance Quote

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Producer Info

Producer Name:

Date:

Producer Email:

Producer Phone:

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Client Details

Client Name:

Date of birth:

Gender:

Male

Female

Height:

Weight:

Tobacco Use:

Cigarette/vaping/e-cig

Former smoker

Other tobacco use

No tobacco use

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Application Details

Coverage Amount:

Coverage Type:

Has client ever been rated or declined for life insurance coverage?

Yes

No

Has this case been assessed and/or shopped by any other brokerage source either formally or informally?

Yes

No

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Client Background

Has client ever been diagnosed with or treated for a condition of the following type(s)? mark all that apply:

Cardiac issues (heart health, i.e. heart attack, murmur, coronary artery disease)

Psychiatric health

Diabetes

Cancer

Diseases/abnormal function of the liver or kidneys

Neurological condition or issues related to cognitive ability, memory

Substance abuse including alcoholism, prescription drug abuse, excessive use of alcohol, etc.

Seizures

Other

Details of any checked condition to include dates of service and all medications and testing

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