Moseleymcgill – Prescription Underwriting Supplement

Prescription Underwriting Supplement 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
Exact name of medication(s):
Exact diagnosis that precipitated prescription:
Dosage:
Results of recent surveillance testing:
Has the client been compliant with the medication?
- Yes
- No
Has the client has any adverse effects from the medication?
- Yes
- No
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

Prescription Underwriting Supplement