Request an Impaired Risk Quote
Producer Info
Producer Name:
First Name Last Name
Date:
Producer Email:
Producer Phone:
Client Details
Client Name:
First Name Last Name
Date of birth:
Gender:
Male
Female
Height:
Weight:
Tobacco Use:
Cigarette smoker
Former smoker
Other tobacco use
No tobacco use
Quit date:
Type of tobacco and frequency:
Application Details
Coverage Amount:
Coverage Type:
Has client ever been rated or declined for life insurance coverage?
Yes
No
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?
Yes
No
If yes, please advise the date of the assessment, which companies reviewed the file through the alternate source and whether offers were made:
Client Background
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)
Psychiatric health
Diabetes
Cancer
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.
Seizures
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)
Heart attack
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
Cardiac catheterization
Angioplasty
Bypass surgery
Date of cardiac catheterization:
Date of angioplasty:
Was stenting performed?
Yes
No
Date(s) of stenting:
Which arteries?
Date of bypass surgery:
# of vessels involved:
Date of heart attack(s):
Date of abnormal cardiac evaluation results:
Has follow up testing:
Been scheduled
Been completed
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.
Pacemaker?
Yes
No
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?
Yes
No
Date of hospitalization:
Reason(s) cited for hospitalization:
Duration of hospitalization:
Does client have any history of suicidal ideations or suicide attempts?
Yes
No
Please provide the dates of any/all suicidal episodes.
Diabetes type:
Type I
Type II
Age/date diagnosed with diabetes:
Does client have history of any of the following:
Diabetic neuropathy
Hypertension
Vascular issues
Diabetic retinopathy
Please provide details including corresponding dates and treatment(s).
Most recent A1C test result:
ex: 6.0
Is most recent A1C consistent with A1C level from prior testing?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
Has client scheduled or completed follow up testing?
Scheduled
Completed
No
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
Memory loss
Impaired cognitive ability
Dementia, Alzheimers
Date/age at dementia onset:
Cause:
Has client been diagnosed with alzheimers?
Yes
No
Date of alzheimers onset:
Is memory loss related or attributed to an existing condition?
Yes
No
Condition name/type:
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.
Alcohol
Cocaine
Prescription medication
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?
In-patient rehab
Outpatient-rehab
No
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?
Voluntarily
Mandated
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
Generalized absence
Complex partial
Simple partial
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.
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