Prescription Underwriting Supplement 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Exact name of medication(s): Exact diagnosis that precipitated prescription: Dosage: Results of recent surveillance testing: Has the client been compliant with the medication?YesNo Has the client has any adverse effects from the medication?YesNo Has the client been prescribed medication by his/her doctor that he/she has decided to discontinue on his/her own? If yes, please explain. 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