Post-Traumatic Stress Disorder 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

Post-Traumatic Stress Disorder Questionnaire

When was the proposed insured first diagnosed with post-traumatic stress disorder?(Required)

Does the proposed insured experience any of the following symptoms?

Reliving the event

Anxiety

Panic attacks

Psychosis

Difficulty sleeping

Outbursts of anger or irritability

Difficulty concentrating

Fear for their safety

Other

If other symptoms, please specify

Has the proposed insured ever been hospitalized as a result of this condition?

Yes

If yes, provide details

Has the proposed insured ever been disabled as a result of this condition?

Yes

If yes, what is the monthly disability income?

How is the proposed insured being treated for this condition?

Medication

Therapy

Other

If therapy, frequency of visits

If other treatment, please specify

Has the proposed insured ever attempted suicide?

Yes

Does the proposed insured have any history of substance abuse?

Yes

If yes, provide details

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.