Depression / Anxiety Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Depression / Anxiety Questionnaire

What diagnosis was given?(Required)

Date of diagnosis

Number of episodes

Date of last episode

Was the depression or anxiety described as bipolar or manic?

Yes

Was the depression or anxiety related to a specific event?

Yes

If yes, describe the event

Was the proposed insured hospitalized?

Yes

If yes, provide details and dates

Did the proposed insured ever attempt suicide?

Yes

If yes, provide dates

Type of treatment

Did the proposed insured take any medications to treat the depression or anxiety?

Yes

If yes, provide the name, dosage and frequency of the medications

Is the proposed insured still taking the medications?

Yes

If no, date last used

Was any time lost from work, or from not being able to perform regular daily activities?

Yes

If yes, how much time?

Is the proposed insured seeing a psychiatrist?

Yes

If yes, how often?

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.