Impairment Prequalification

Send an impaired risk case straight to our underwriting desk, or download the questionnaire your carrier will ask for. Most cases come back with direction inside one business day.

Start a general request

How this works

Find the impairment below and select it. Each one opens its own questionnaire, built from the same underwriting questions the carrier will ask, so you are not guessing at what to send. Submitting routes it straight to a Brookfield underwriter.

Most questionnaires also have a printable PDF. Use it when you would rather collect answers from your client first, or when a carrier asks for the completed form as an attachment. If the impairment is not listed, use the general questionnaire at the bottom of this page.

Health and medical impairments

Lifestyle, avocation and non-medical

General questionnaires

Impairment not listed?

Use the general questionnaire below and tell us what the impairment is. It reaches the same underwriting desk.

Agent & Case Information

Agent Name(Required)

Proposed Insured

Client Name(Required)
You may enter client initials. We don't share client information with carriers on risk assessments.
Sex(Required)
Tobacco / Nicotine Use(Required)

Coverage Requested

Type of Insurance

General Use Questionnaire

Has there been any treatment?
Are there any other health issues?
Additional questionnaires may be required.
Any family history of health impairments?
Parent, sibling and so on.
Is the proposed insured currently taking any medication(s)?

Attachments

Drop files here or
Max. file size: 512 MB.
    Attach medical records, lab slips, pathology or test reports.

    Rather talk it through first?

    If the case is complicated or time sensitive, call the underwriting desk at 866.639.0443 and we will work through it with you before anything goes to a carrier.

    Schedule a call