Other Impairment Questionnaire

Agent Name :

Agent Phone :

Agent Fax :

Agent Email :

Client Name :

Client Age :

Client DOB :

Client Sex :

Client Height :

Client Weight :

Please list any and all details related to your client's impairment :

What type of insurance is desired ?

If you selected term, what is the desired term length ?

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 :

If yes, please list the type, frequency, and amount of tobacco used :

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

If yes, please give a detailed description of problem(s) :

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

If yes, please list which family member(s), give a detailed dscription of their condition(s), and list which, if any, are living or non-living :

Additional Comments :