Preferred 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 Client Height: MM slash DD slash YYYY Client Weight: Date of last routine physical: MM slash DD slash YYYY Plan: List health conditions below:Click the + sign to provide additional conditions. ConditionDate DiagnosedMedicationsTreatment/Surgery Family history (cancer, cardiovascular, diabetes diagnosis, or death in parents or siblings)Click the + sign to provide additional relatives. RelativeDiagnosisAge of DiagnosisAge at Death Motor vehicle history (last 5 years): List any other major health problems the client has: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