The following questions are designed to help establish potential underwriting classifications, identify the best potential insurance company and avoid quoting rates that an insurance prospect will not qualify for. Life Insurance rates are as competitive as they have ever been. However, insurers and their re-insurers have agreements and strict guidelines when determining an underwriting classification. In most cases there  can be NO exceptions to offers it it is due to one of the published carrier guidelines.

Underwriting classes offered by our underwriter are non-binding. They are to be used as a starting point for premiums during the insurance process.

Every insurance company has slight variations to underwriting guidelines. In some instances, one minor issue can result in Standard Rates at one company and Preferred Best at another company. By gathering detailed and accurate information, we can deliver the best potential carrier based on our client’s objectives, premium and underwriting for any Life, Disability or Long Term Care Insurance Product. We know the carriers and know where to go for everyday cases and really tough ones!

This form is designed to be completed by the Proposed Insured. This information is confidential, and will not be shared with carrier underwriters.

  • Proposed Insured Information

  • If our Underwriter has additional questions, who should they contact?
  • Please include either e-mail, phone, or both.
  • Ex: 5'6"
  • Cigarettes, E-Cigarettes, Chewing, Vape
  • MM slash DD slash YYYY
  • Personal History Questions

    Do you have a personal history of the following conditions?
  • Including Heart Attack, Coronary Artery Disease, Arrhythmia, Valvular Disease, Heart Murmur, Cerebrovascular Disease, Stroke, or TIA?
  • Please provide Name of Medication, Dosage, and Frequency.
  • Actual Planned Trips only. If yes, please provide dates, city, country, length of stay in the details section below.
  • If you know your A1C, Blood Pressure Readings, or Cholesterol Readings, let us know!
  • Disability Insurance Supplement

    Please complete if applying for Disability Insurance.
  • Including any visits to a Chiropractor or other specialists?
  • (i.e., Depression, Anxiety, Psychotherapy Visits?)
  • Long Term Care Insurance Supplement

  • Advisor Information