Mature Age Lifestyle

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Mature-Age Lifestyle Questionnaire
The purpose of this questionnaire is to help your underwriter get to know the proposed insured beyond what is written in an APS or what is on the medical exam. The list of questions below will help us better position your case. Please elaborate as much as possible.

NOTE: This form should be completed if the proposed insured is age 70 or above.

Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
What activities does the proposed insured routinely participate in? (golf, travel, cards, etc.)?
Does the proposed insured participate in any type of exercise routine?
- Yes
- No
If so, please elaborate.
Does the proposed insured drive?
- Yes
- No
If no, why not?
Does the proposed insured use any assistive devices? (cane, walker, etc.)?
- Yes
- No
Is there a history of falling by the proposed insured?
- Yes
- No
Does the proposed insured manage his/her own financial affairs/investments?
- Yes
- No
Is the proposed insured employed?
- Yes
- No
If not employed, is the proposed insured involved in any volunteer or charity work?
- Yes
- No
What are the proposed insured’s hobbies?
What does owning an insurance policy mean to the proposed insured and what is the ultimate purpose he/she wants this policy to fulfill?
What other factors will enable us to favorably present the application to the insurance company underwriters?
For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections

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Moseley McGill, LLC is a Marketing Firm assisting Insurance Professionals in Estate Creation, Protection and Preservation, Quoting Services, Advanced Case Design and Case Management.

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(877) 564-1707
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Mature Age Lifestyle

Mature-Age Lifestyle Questionnaire