Impaired Risk
Other Conditions Questionnaire
Agent Information
Agent Name
(required)
Address
Phone
(required)
Fax
E-Mail
(required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth
mm
dd
yy
Sex
M
F
Height
Feet
2 '
3 '
4 '
5 '
6 '
7 '
8 '
9 '
Inches
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs.)
Smoker
Yes
No
(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type
Select one
Term
UL
Survivor UL
Additional
insured's name
(only if applying
for Survivor UL)
Other company(s) actions
Date applied
mm
yy
Company
Declined
Postponed
Rated table
1. What is client's illness?
please provide details
2. When was diagnosis made?
mm
yy
3. What type of treatment has been received?
surgery month/year
medication (list)
other types of treatment
4. When was last visit to a physician about this disorder?
select one
0-6 months
6-12 months
12-24 months
more than 24 months ago
5. Date and result of last cholesterol reading.
mm
yy
6. Date and result of last blood pressure reading.
mm
yy
7.
How many times per week does client exercise?
select one
None
1 time per week
2 times per week
3 times per week
4 times per week
5 times per week
6 times per week
7 times per week
More than 7
Type of exercise
8. Are there any other illnesses/impairments?
9. What medication is currently being taken?
10. Has either parent, or any sibling, died before age 65, other than by accident?
Yes
No (If yes, list relationship(s) and cause)
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
Additional Information