Mature-Age Lifestyle QuestionnaireThe 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 MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas 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 Δ