Pre-Underwriting QuestionnairePlease 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 AmountMax Premium $/yearTypeTermPermanentHas 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 DiseaseIf Cancer, Type of CancerAge of OnsetAge 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 OnsetTreatment GivenIrregular heart beatAny History of?Date of OnsetTreatment GivenValve disorderAny History of?Date of OnsetTreatment GivenCoronary artery diseaseAny History of?Date of OnsetTreatment GivenDate 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 catheterizationDateResultsEver Have?Bypass surgery (CABG)DateResults# of vesselsEver Have?Angioplasty (PTCA)DateResults# of vesselsEver Have?Valve surgery or replacementDateResultsWhich valve?Ever Have?StentingDateResultsWhich 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. CountryCityDuration of stayFrequencyPurpose 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 Δ