Respiratory 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

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

Respiratory Disorders Questionnaire

What was the proposed insured's diagnosis?(Required)

Asthma

Bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

Emphysema

Other

If other, please specify

Has pulmonary function testing been done?

Yes

If yes, what type of test?

Forced Vital Capacity (FVC)

Forced Expiratory Volume (FEV1)

Other

Dates and results of testing

Has a chest X-ray been done?

Yes

If yes, provide date and results

Are the attacks caused by any special circumstances or conditions?

Yes

If yes, provide details

Frequency of attacks or hospitalizations

What medications have been taken to relieve the attacks?

Has the proposed insured ever been given cortisone or any other steroids?

Yes

If yes, provide dates and dosage

Does the proposed insured have any other medical conditions?

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.