Skip to content
Menu
Who We Are
Our Story
We understand your business and are dedicated to our advisors, creating a spirit of camaraderie and success so you can make more money, in less time, and enjoy the journey.
Our Team
Our team works together to create an ecosystem focused on advisor success, providing the support you need to take your business to new heights.
What We Do
Products & Carriers
We serve multiple lines of business; Life, Annuity, Long Term Care, and Disability. Our stable of over 50+ carriers makes it easy to select the right product for your client’s solution.
Operations Platform
We help you expedite product, processes, and payouts with state-of-the-art technology, creative underwriting, and broad carrier access.
Illustration Request & Design
Need to send us a request for an illustration or case design? Have a question on the best carrier or product? We can help you here.
How We Help
Strategic Marketing
We help you attract clients, generate revenue, and amp business growth with unique strategies and our high-level business accelerator model.
Business Branding
We help you define your brand, creating logos, business cards and other marketing materials you need to make your mark.
Advisor Basecamp
Our toolbox provides everything you need to write business at your fingertips, making your journey to the top faster and easier.
Contact
Get In Touch
Contact us for help with any producer related question or concern. Our goal is your success.
Insured Individuals
Need help with a claim or question? We can help you right here.
Login
Close Menu
Underwriting Questionnaire
Preliminary Underwriting Questionnaire
Underwriting Questionnaire
Section 1: Proposed Insured
Full Name:
(Required)
Social Security Number:
(Required)
Date:
(Required)
MM slash DD slash YYYY
Martial Status:
Married
Single
Divorced
Widowed
Sex:
(Required)
Male
Female
Place of birth:
(Required)
Occupation/Employer:
Home Address:
City:
State:
Zipcode:
Years Residing at Address:
Driver's License #:
DL State / Exp:
Citizenship:
Section 2: Current & Desired Coverage Information
Amount of Coverage Requested:
Type of Coverage:
Will Insurance Premium be Financed?
Yes
No
Annual Income (Earned & Unearned):
Net Worth:
Do you have current coverage?
Yes
No
Do you plan on replacing coverage?
Yes
No
Please list all current coverage or applied for coverage.
Company:
Face Amount:
Issue Year:
Policy Type:
Company:
Face Amount:
Issue Year:
Policy Type:
Company:
Face Amount:
Issue Year:
Policy Type:
Company:
Face Amount:
Issue Year:
Policy Type:
Section 3: Physician Information (last 10 days)
Primary Care Physician/Facility:
Phone:
Fax:
Address:
City:
State:
Zipcode:
Date of Last Visit & Reason:
Specialist/Facility:
Phone:
Fax:
Address:
City:
State:
Zipcode:
Date of Last Visit & Reason:
Specialist/Facility:
Phone:
Fax:
Address:
City:
State:
Zipcode:
Date of Last Visit & Reason:
Section 4: Medical Information
Please check Yes or No for all questions. If yes answer applies to any question, provide details such as date of first diagnosis, name and address of doctor, test performed, test results, and medications prescribed in the space provided in a section 6 of the questionnaire.
1. Approximate height / weight:
2. Has the proposed insured ever used tobacco?
Yes
No
If yes, please list date last used:
MM slash DD slash YYYY
3. Are you currently taking any medication, treatment, therapy, or under medical observation?
Yes
No
4. Has the proposed insured ever been diagnosed as having, been treated, or consulted a license health care provider for:
A. Heart disease, heart attack, chest pain, irregular heartbeat, heart murmur, abnormal EKG / ECG or any other disorder of the heart?
Yes
No
B. COPD, asthma, bronchitis, emphysema, sleep apnea, or other breathing or lung disorders?
Yes
No
C. Elevated cholesterol or blood pressure?
Yes
No
D. Diabetes, a disorder of the thyroid or other glands, or a disorder of the immune system, blood or lymphatic system?
Yes
No
E. Cirrhosis, colitis, hepatitis or a disorder of the stomach, liver, pancreas, gall bladder or intestines?
Yes
No
F. Prostate or testicular disease, a disease of the uterus, ovaries, or the breast?
Yes
No
G. Seizures, a disorder of the brain or spinal cord, or other nervous system abnormality including depression, mental or nervous disorder?
Yes
No
5. In the past ten years, has the proposed insured:
A. Been hospitalized, consulted a health care provider or had any illness, injury, or surgery?
Yes
No
B. Had any laboratory test or treatments, including x-rays, scans, and EKG?
Yes
No
6. Family Health History - Medical Information
A. Has any immediate family member (parent or sibling) died prior to age 60?
Yes
No
B. Has any immediate family member (parent or sibling) ever been diagnosed with high blood pressure, elevated cholesterol, or cancer?
Yes
No
Section 5: Non-medical Questions
Please check yes or no for ALL questions. If yes, answer applies to any question provide details in section 6 of the questionnaire.
7. Within the next 2 years do you plan to fly, or within the last 2 years have you flown, as a pilot, student pilot, or crew member?
Yes
No
8. Within the next 2 years do you plan to participate in, or within the last 2 years have you participated in, parachute jumping, scubadiving, auto/motorboat/motorcycle racing, hang gliding, or mountain climbing?
Yes
No
9. Do you expect to travel or reside outside the USA?
Yes
No
10. Have you ever been convicted of a felony within the past 5 years?
Yes
No
11. Have you had your driver's license restricted or revoked or been convicted of 3 or more moving violations within the past 5 years?
Yes
No
Section 6: Details
Please explain any questions answered YES from all sections of the questionnaire. Attach additional sheets if necessary.
Please list details below:
CAPTCHA
Δ
