Impaired Risk - HBW Insurance & Financial Services, Inc.

In order to get the most accurate underwriting, please be as thorough as possible. Failing to include information may completely change underwriting results.

Agent Information

Agent Name
Agent Fax

Agent Phone
Agent Email

Client Information

Client Name

Client Age

Client DOB

Client Sex

Client Height

Client Weight

Underwriting Questions Pertaining to Asthma

What date was your client diagnosed?
Has your client ever been hospitalized for this condition? Yes: No:

How many episodes of Asthma has your client had in the past year that required him/her to go to the ER or see their physician for treatment?
Have pulmonary function tests (a breathing test) ever been done? Yes: No:

Does your client have any abnormalities on an ECG or x-ray? Yes: No:

General Underwriting Questions

Has your client recently been rated or declined for coverage? Yes: No:

What type of insurance is desired?

	Term
	Universal
	Whole life

What is the desired Face Amount?

Please list your client's current medications and the reasons they are taking them:

Has your client used tobacco in the last 12 months? Yes: No:

Does your client have any other major health problems? Yes: No:
^{(Ex: Cancer, diabetes, ulcers, etc. )}

Do any of your client's relatives have a history of the impairment or any other medical conditions? Yes: No:

Additional Comments :

Please press submit only once per case.

Impaired Risk Cases

Asthma Impairment Questionnaire

Agent Information

Client Information

Underwriting Questions Pertaining to Asthma

General Underwriting Questions

Call Toll Free!

Quick Links