Personality Disorders 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

Advisor Information

Advisor Name(Required)

First Last

Advisor E-Mail(Required)

Advisor Phone Number(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)

Gender(Required)

Height(Required)

Weight(Required)

Tobacco Use

Never used

Totally stopped

Uses now

If stopped, date stopped

Type of nicotine product

Type of Coverage

Term

Survivor UL

Coverage Amount

Anticipated Premium

Personality Disorders Details

Date of diagnosis(Required)

Please note which type of personality disorder has been diagnosed

Antisocial

Narcissistic

Borderline

Histrionic

Paranoid

Dependent

Schizoid

Obsessive compulsive

Schizotypal

Avoidant

Has the client been hospitalized for a psychiatric illness?

Yes

Hospitalization dates and details

Does the client have any of the following associated conditions?

Substance abuse (alcohol or drugs)

Mood disorder such as depression

Suicidal thought or attempt

Other psychiatric disorder

Details for any of the above

Current medications

Accurate name, dosage and reason for each.

Are there any other health issues?

Yes

Additional questionnaires may be required.

Other health issue details

Additional Information

Family history

Has a parent, brother or sister had cancer, diabetes, stroke, heart or kidney disease, or died by suicide? Include age of onset and date of death.

Existing insurance

Company, face amount, year issued, and whether the policy is to be replaced.

Desired product type and face amount

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.