Pre-Underwriting

Pre-Underwriting Questionnaire
Please answer all questions applicable to the client's medical history.
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 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
Has the case been submitted to other companies in the last 12 months?
- Yes
- No
If yes, list companies, dates, and action taken:
Date of last routine physical:
MM slash DD slash YYYY
Please list any health conditions.
Please list any medications being taken (including over-the-counter).
Height:
Weight:
Average weight change in past 12 months:
Latest blood pressure reading:
Date
MM slash DD slash YYYY
Cholesterol/HDL results:
Date
MM slash DD slash YYYY
Family history: Has any immediate family member (parents or siblings) had death or disease up to age 65 from cancer, diabetes, cerebrovascular disease, or heart disease? If yes, complete the information below.
Click the + sign to add additional relatives.
Relation (Mother, Father, Brother, Sister) Type of Disease If Cancer, Type of Cancer Age of Onset Age at Death (if Deceased)
Alcohol/Drug Abuse?
- Yes
- No
Current user?
- Yes
- No
Duration used:
Date stopped using:
Kind of substance:
Amount used:
Type of treatment:
Attend AA/NA or other programs?
- Yes
- No
Any relapses?
- Yes
- No
Any motor vehicle violations or DUIs?
- Yes
- No
If yes, provide details:
Asthma/COPD
- Yes
- No
When diagnosed?
Number of attacks per year:
Date and severity of last attack:
Are attacks seasonal?
- Yes
- No
Any hospitalizations?
- Yes
- No
If yes, when?
Aviation
- Yes
- No
Total hours flown as pilot or co-pilot:
IFR?
- Yes
- No
Hours flown per year:
Type of license:
Purpose (civilian, military, etc.):
Cancer?
- Yes
- No
Type
Location
Staging
Grading or copy of pathology report
Any positive lymph nodes?
- Yes
- No
Depth, level, or Gleason Score
Date of surgery
MM slash DD slash YYYY
Any radiation or chemo?
- Yes
- No
If yes, date treatment ended
Any recurrence of cancer?
- Yes
- No
If yes, provide details
Cardiac Disorders
- Yes
- No
MI (heart attack)
Any History of? Date of Onset Treatment Given
Irregular heart beat
Any History of? Date of Onset Treatment Given
Valve disorder
Any History of? Date of Onset Treatment Given
Coronary artery disease
Any History of? Date of Onset Treatment Given
Date of last cardiologist visit:
MM slash DD slash YYYY
Reason:
Date of last stress test:
MM slash DD slash YYYY
Results:
Date of most recent echocardiogram:
MM slash DD slash YYYY
Results:
Ever Have?
Coronary catheterization Date Results
Ever Have?
Bypass surgery (CABG) Date Results # of vessels
Ever Have?
Angioplasty (PTCA) Date Results # of vessels
Ever Have?
Valve surgery or replacement Date Results Which valve?
Ever Have?
Stenting Date Results Which vessels?
Crohns?
- Yes
- No
Colitis?
- Yes
- No
Date diagnosed:
MM slash DD slash YYYY
Any hospitalizations or surgery?
- Yes
- No
If yes, what?
Diabetes?
- Yes
- No
Date diagnosed?
MM slash DD slash YYYY
Treatment (oral meds, insulin, diet):
Units of insulin:
Names of medications:
Number of regular doctor visits per year:
Any complications:
Last fasting blood sugar and date:
Last glycohemoglobin (A1c) and date:
Foreign Travel/Foreign Residence
- Yes
- No
Citizenship:
Type of Visa
Does client have a green card?
- Yes
- No
Answer the following if the client is not a US citizen:
How long in the US? Works in the US? Owns property in the US? US bank account?
Travel outside the US:
Click the + sign to add additional trips.
Country City Duration of stay Frequency Purpose of Travel
Hepatitis?
- Type A
- Type B
- Type C
Date diagnosed:
MM slash DD slash YYYY
Cause:
Current status:
- Active
- Cured
Medications/date of last use:
Current alcohol use/amount:
Hypertension?
- Yes
- No
Date diagnosed:
MM slash DD slash YYYY
Average readings:
Are readings monitored at home?
- Yes
- No
Lab Abnormalities?
- Yes
- No
What tests were abnormal?
Results/date(s):
Any diagnosis given:
How long has test been abnormal?
Multiple Sclerosis?
- Yes
- No
Lupus?
- Yes
- No
Date diagnosed:
MM slash DD slash YYYY
Last attack:
Attack frequency:
How long do attacks last?
Any disability?
Mental Disorders/Depression/Anxiety
- Yes
- No
Diagnosis:
Date
MM slash DD slash YYYY
Hospitalization?
- Yes
- No
Suicide attempt(s)?
- Yes
- No
Currently employed?
- Yes
- No
Seizure Disorder/Epilepsy?
- Yes
- No
Date of last seizure:
MM slash DD slash YYYY
Date of diagnosis:
MM slash DD slash YYYY
Type of seizure:
Frequency of seizures:
Sleep Apnea?
- Yes
- No
Date diagnosed:
MM slash DD slash YYYY
Is CPAP used every night?
- Yes
- No
Date of last sleep study:
MM slash DD slash YYYY
Sleep study results:
- Mild
- Moderate
- Severe
Was surgery done?
- Yes
- No
If yes, type:
TIA/CVA (transient ischemic attack-ministroke/stroke)?
- Yes
- No
Date of episode:
MM slash DD slash YYYY
Number of episodes:
Any residuals:
Type of treatment/medication:
Avocations (scuba, mountain climbing, etc.)?
- Yes
- No
Specify:
Impairments not listed?
- Yes
- No
Diagnosis given:
Date
MM slash DD slash YYYY
Treatment:
Medications:
Date of last followup:
MM slash DD slash YYYY
Test results:
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

Relation (Mother, Father, Brother, Sister)	Type of Disease	If Cancer, Type of Cancer	Age of Onset	Age at Death (if Deceased)

Country	City	Duration of stay	Frequency	Purpose of Travel

Pre-Underwriting

Pre-Underwriting Questionnaire