Request an Impaired Risk Quote
First Name Last Name
First Name Last Name
Date of birth:
Other tobacco use
No tobacco use
Type of tobacco and frequency:
Has client ever been rated or declined for life insurance coverage?
If yes, please provide the carrier, date of the application or when policy was issued, the rated class/offer and the reason cited for the rating or decline.
Has this case been assessed and/or shopped by any other brokerage source either formally or informally?
If yes, please advise the date of the assessment, which companies reviewed the file through the alternate source and whether offers were made:
Has client ever been diagnosed with or treated for a condition of the following type(s)? mark all that apply:
Cardiac issues (heart health, i.e. heart attack, murmur, coronary artery disease)
Diseases/abnormal function of the liver or kidneys
Neurological condition or issues related to cognitive ability, memory
Substance abuse including alcoholism, prescription drug abuse, excessive use of alcohol, etc.
Date of most recent follow up cardiac visit and/or testing? Were all results favorable? If no, please provide details.
Please mark all cardiac history items that apply:
Coronary artery disease (CAD)
Abnormal cardiac testing without prior diagnosis
Atrial fibrillation ("a-fib")
Please list all treatments received with corresponding start/end dates, dosages and any other pertinent information.
Date/age of CAD diagnosis:
Has client received/undergone any of the following? Mark all that apply
Date of cardiac catheterization:
Date of angioplasty:
Was stenting performed?
Date(s) of stenting:
Date of bypass surgery:
# of vessels involved:
Date of heart attack(s):
Date of abnormal cardiac evaluation results:
Has follow up testing:
Date follow up testing was completed with details of prognosis/diagnosis:
When is follow up testing to be completed?
# of A-fib episodes:
If other, provide the name/type of diagnosis with diagnosis date and pertinent details including procedures, episodes, etc.
Name/type of psychiatric diagnosis:
Date of psychiatric diagnosis:
Please list all treatments received including medication with corresponding start/end dates and dosages, counseling, etc.
Has client ever been hospitalized in relation to psychiatric health?
Date of hospitalization:
Reason(s) cited for hospitalization:
Duration of hospitalization:
Does client have any history of suicidal ideations or suicide attempts?
Please provide the dates of any/all suicidal episodes.
Age/date diagnosed with diabetes:
Does client have history of any of the following:
Please provide details including corresponding dates and treatment(s).
Most recent A1C test result:
Is most recent A1C consistent with A1C level from prior testing?
If not consistent, please explain.
Type/name of cancer:
Date of diagnosis:
Date of last treatment(s):
Date considered "in remission" or "cancer free" by physician:
Stage of cancer:
Grade of cancer:
Please provide start/end dates for all treatments received including medication treatment, surgical procedures, chemotherapy, etc.
Any incidence of recurrence?
If yes, provide details including date(s) of recurrence, treatment(s) and results of follow up evaluations.
Does client currently have or have they ever been treated for a health condition related to the liver or kidneys?
Please provide the type/name of diagnosis with the date diagnosed and all treatments received.
Has client tested abnormally on laboratory testing, without prior diagnosis or an existing condition, for functions of the liver and/or kidneys?
Date of abnormal laboratory testing:
Which test results were abnormal? Please provide details.
Does client currently or has client previously used alcohol in excess or been told by a physician that they should cease or "cut back" their alcohol use? If yes, provide details.
Is this the first time client's test results have been abnormal?
Has client scheduled or completed follow up testing?
What were the results of the follow up testing? Has a prognosis or diagnosis been made? Please provide details.
When is the follow up laboratory testing scheduled for?
Does client suffer from any of the following? Please mark all that apply
Impaired cognitive ability
Date/age at dementia onset:
Has client been diagnosed with alzheimers?
Date of alzheimers onset:
Is memory loss related or attributed to an existing condition?
Date of initial diagnosis:
How is condition monitored and/or treated?
Has cognitive impairment impacted the client's ability to perform daily activities such as household items, working or any other day-to-day tasks? Please provide details and describe the level of disability.
Which substances does client have history of abusing or using excessively? Please mark all that apply.
Date(s) of last use:
Details of usage including frequency and history of any impact there may have been on daily life such as employment, legal affairs, marriage, etc.
Has client ever undergone rehabilitation therapy for substance abuse?
Private counseling and/or support groups
Start date and completion (release) date:
Start date and end date (if currently undergoing out-patient treatment, "current")
Did client enter rehab voluntarily or as the result of a court mandate/sentencing?
Please provide details of the incidents leading to the court mandated rehabilitation including explanation of the events, dates of court hearings, arrests, sentencing hearings and any/all probation terms.
Has it been recommended to the client by their physician that they undergo professional in-patient or out-patient substance abuse treatment?
What condition/disorder are seizures related to?
Date of onset:
Which type(s) of seizures does client experience:
Generalized tonic-clonic or convulsive
Atonic seizures ("drop attacks"
Frequency of seizures:
Duration of seizures:
Severity of seizures:
Please provide details of all treatments for seizure episodes and for those used to treat the underlying condition.
For any/all other medical impairments, please provide details of the name/type of condition, diagnosis date, treatment types & dates and all other pertinent details.
Should be Empty: