Preferred Underwriting

Preferred 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
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.
Condition Date Diagnosed Medications Treatment/Surgery
Family history (cancer, cardiovascular, diabetes diagnosis, or death in parents or siblings)
Click the + sign to provide additional relatives.
Relative Diagnosis Age of Diagnosis Age 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

Condition	Date Diagnosed	Medications	Treatment/Surgery

Relative	Diagnosis	Age of Diagnosis	Age at Death