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 Race Car Driving

Does your client hold a competition license? Yes: No:

What racing schools has your client attended?
Is your client an amateur or professional racer? Amateur: Professional:

What racing divisions does your client participate in and who is the sanctioning body?
How often and where does your client race?
Please describe the car used: displacement, maximum HP, chassis and maximum speed:
Does your client intend to race in any other classes/divisions? 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

Race Car Driver Impairment Questionnaire

Agent Information

Client Information

Underwriting Questions Pertaining to Race Car Driving

General Underwriting Questions

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