Informal Inquiry. Name Male Female SSN. Address City State Zip. Date of Birth Age Height. Monthly Earned Income $

Transcription

1 Informal Inquiry Preliminary Inquiry Not an application for life insurance. This informal inquiry form is used exclusively to gather specific information on a proposed insured s medical history and other factors that may impact underwriting and rating classification. This is not an application for insurance and in not way guarantees a specific underwriting class or binds any insurance coverage with any insurance carrier. Personal History Name Male Female SSN Address City State Zip Date of Birth Age Height Weight Home Phone Number Work Phone Number Occupation Monthly Earned Income $ Are you a US citizen? Yes No If No, please advise date of entry into the US Tobacco/Nicotine Usage Have you ever smoked cigarettes? Yes No If Yes, date of last usage Have you used other tobacco or nicotine-containing products? Yes No Agent Information Name SSN Phone Number Address City State Zip Address Requested Plan of Insurance Universal Life Variable Life Whole Life Term, Level Period Survivorship Face amount desired $ Premium amount desired $ Please choose a pay mode: Annually Semi-Annually Quarterly Monthly Will these premiums be financed? Yes No If you are replacing coverage, will there be any 1035 money with this replacement? Yes No If Yes, what amount will be carried over? $ What is the purpose of insurance? 1 of 4

2 Provide details on pending and inforce coverage: Company Policy Date Face Amount Class Issued Current Premium Replacing? Medical History Primary care physician (PCP) Date last seen Reason last seen Results of visit PCP Address City State Zip What other physicians have you consulted during the past five years? Why? In what hospitals, clinics, or other health facilities have you ever been treated? Please provide approximate dates. Please list all current medications 2 of 4

3 Family History Have any immediate family members (parents or siblings) been diagnosed or died from heart disease or cancer? Yes No If Yes, please provide the following details: Relationship Diagnosis Approximate age of disease onset (If deceased) Age at death Drug and Alcohol Usage Questionnaire Do you currently drink alcohol? Yes No Date of last consumption Did you ever drink substantially more than present? Yes No Note amounts below. Type Amount per week Beer Wine Liquor Have you ever consulted a doctor or received treatment because of your alcohol abuse? Yes No Have you ever been arrested for driving under the influence of alcohol? Yes No If yes, provide date(s) Have you ever used illegal drugs or sought treatment because of drug use? Yes No If Yes, provide details: Type(s) of drugs used Date of last use Doctor/Facility name and address 3 of 4

4 Coronary Date of diagnosis or first chest pain Number of diseased vessels Dates/details of treatment/surgery Date of last stress EKG Doctor/Facility name and address Results Cancer Exact type and location of cancer Stage and grade Who would have the pathology report? Dates/details of treatment/surgery Diabetes Date of diagnosis Treatment: Diet Only Oral Medication Insulin Other: Do you regularly test your blood glucose? Yes No Latest result of glycohemoglobin (A1C) test mg% Date Have you ever been diagnosed with having protein and/or microalbumin in your urine? Yes No Have you ever had any of the following: eye trouble heart trouble high blood pressure kidney trouble neuritis/neuralgia insulin reactions 4 of 4

5 ProposedInsured sname DateofBirth SocialSecurityNumber This%form%is%HIPAA%Compliant% RecordsandinformationobtainedfromtheProposedInsuredorotherpartiesmaybedisclosedtoandbetweentheinsurancecompaniesortheinsuranceagencieslist below,producerresources,inc.,brokers,contractors,employees,representativeandagentsworkingthroughproducerresources,inc.fortheproposedinsuredapplying fororevaluatinginsurancecoverage. Insurance%Companies%and%Agencies% Accordia AdvantageInsuranceNetwork,Inc. Allianz AmericanGeneralLife(AIG) AmericanNational Americo AssurityLife Aviva/IndianapolisLife Ameritas AVS,LLC AUSUnderwriting AXA/MONY/AXAEquitable BannerLife ColumbusLife ConcordCapital/INSCAP CoventryFirst,LLC Dr.JackCotlar EMSI EquityKey,LLC EquityRelease ExceptionalRiskAdvisors ExpressImagingServicesInc. FirstFinancialResources FirstGlobalFinancial&Insurance FirstInsuranceFunding FirstPenn Foresters GeneralAmericanLifeIns.Co. GlobalInsuranceUnderwriters GEFinancialAssuranceCo. GenworthLifeInsuranceCo. GenworthLifeandAnnuity GuardianLifeIns.Co JohnHancockLifeIns.Co. JohnHancockUSA LafayetteLife LifeInsuranceoftheSouthwest LifeShare LincolnFinancial/LincolnLife LincolnNationalLifeIns.Co. Lloyd soflondon Massachusetts(Mass)Mutual MetropolitanLife MetLifeInvestorsUSAIns.Co. MinnesotaLife/Securian MutualofOmaha NationalLifeofVermont NationalWestern NationwideLife&AnnuityCo. NewInvestorWorld,Inc. NewYorkLifeInsuranceCo. NorthAmericanCo. OneAmerica PacificLife PennMutual PremiumFundingGroup(PFG) PioneerMutual Portamedic PresidentialLife PrincipalLifeInsuranceCompany PrincipalNationalLifeIns.Co. ProducerResourcesInc. ProfessionalUnderwritingServices ProtectiveLifeIns.Co. PrudentialLifeIns.Co./PrucoLife ReliastarLifeIns.Co. ReliastarLifeIns.Co.ofNewYork RSAMedical SBLI SecurityLifeofDenverIns.Co. SecurityMutual StandardLife StrategicMedicalConsulting SuccessionCapital/CMS SuperiorMedicalGroup SymetraFinancial TransamericaLifeIns.Co. TravelersLife&Annuity 21 st Services UnionCentralLife UnitedofOmaha USGAnnuity&Life Voya WestCoastLifeInsuranceCo. WesternReserveLife WilliamPennLifeIns.Co. ZurichAmericanLifeIns.Co. Additional%Insurers%and%Agencies:%% Broker/Agent/Financial%Professional:%% ThepurposeofthisAuthorizationistoassistintheevaluationandplacementofmyapplicationforinsurance.Iherebyauthorizethereleaseofanyandallrecordsand informationregardingme,theproposedinsured,pursuanttothisauthorization.thisincludes,withoutlimitation,anyandallrecordsandprotectedhealthinformation regardingdiagnosis,testing,treatmentandprognosisofmyphysicalormentalcondition,withtheexclusionofpsychotherapynotes.suchrecordsandinformationtobe releasemayinclude,butarenotlimitedto,factsaboutmy:(1)mentalandphysicalhealth;(2)alcohol/drugabusetreatment,(3)pharmacyprescriptions,(4)hivtesting andtreatment,exceptwhereprohibitedbylaw,(5)sexuallytransmitteddiseases,(6)sicklecelltestingandtreatment,(7)laboratorytestresults,(8)otherinsurance coverage,(9)hazardousactivities,(10)character,(11)generalreputation,(12)modeofliving,(13)finances,(14)occupation,and(15)otherpersonaltraits. IunderstandthatanyInsurerorAgencynamedafore,itsreinsurers,andinsurancesupportorganizations,andthosepersonsauthorizedtorepresentthemmayneedto collectsuchinformationforproposedinsurancecoverage.theinsurersandagenciesnamedaforeandtheirreinsurerswillusetheinformationinordertodetermine whetheriaminsurableortoassistintheapplicationandunderwritingprocess.theinsuranceproducermayalsousetheinformationtohelpupdateandimprovemy insuranceprogram. Iherebyauthorizeanymedicalpractitioner,includingmyprimarycarephysicianlistedbelow, PhysicianName(s): PhysicianAddress: Anymedicalfacility,healthplan,healthcareprofessional,laboratory,othermedicalentity,insurancesupportorganization,financialinstitution,consumerreportingagency andmyemployer,togivetheinformationdescribedabovetoproducerresources,inc.,theinsurersandagencieslistedaforeandto: Agent/ProducerName: Iunderstandthatmyinformationwillbekeptconfidential,andwillnotbedisclosedtootherpersonsororganizationswithoutthiswrittenpermissionforthepurposes referencedherein,excepttotheextentthatisnecessaryfor(1)theinsurersandagenciesnamedaforeandtheirreinsurersandotherentitiesrequiredtoconductbusiness; (1)otherinsurerstowhichIhaveappliedormayapply;(3)reinsurers;or(4)otherpersonswhomperformbusiness,professionalorinsuranceservicesforthem.Theymay alsodisclosethisinformationasallowedbylaw.theinformationwillbeusedbytheinsuranceand/orsettlementcompaniesnamedbelowandtheirreinsurersto determineeligibilityforinsuranceand/orbytheinsuranceagenttoaidinupdatingandimprovingmyinsuranceprogram.theinformationcollectedmabedisclosedto otherinsurancecompaniestowhichihaveappliedormayapply,settlementcompanies,reinsurancecompanies,themedicalinformationbureau,orotherpersonsor organizationsperformingbusiness,professional,orinsurancefunctionsfortheinsuranceand/orsettlementcompaniesnamedbelow,orasmaybeotherwiselegally allowed. IunderstandthatwheninformationisusedordisclosedpursuanttothisAuthorization,itmaybesubjecttoreidisclosurebytheinsurancecompanyandmaynolongerbe protectedbythefederalandstatelawsandregulationsthatmayhaveappliesinthefirstinstance.thisauthorizationwillremainineffectfor24monthsfromthedateof mysignaturebelow. IunderstandImayrevokethisAuthorizationatanytimebyrequestingsuchofmyagent/brokerinwritingandsenttothehealthcareprovider,ifrequired.Iunderstand thatsuchrevocationwouldnotbeeffectivetotheextentanyofthepartieshereinhavealreadyrelieduponthisauthorization. AphotocopyofthisAuthorizationisasvalidasanoriginal.IacknowledgethatIhavereceivedacopyofthisAuthorizationandtheNoticetoProposedInsured(s).Ifminor childrenareproposedforcoverage,theabovestatementsaremadebythepersonauthorizedtoactontheirbehalf. IunderstandthatIamnotrequiredtosignthisAuthorization.Iunderstand,however,thatifIdonotsignthisAuthorizationtoreleasemyrecordsandinformationthatthe insurersandagencieslistedhereinmaynotbeabletoevaluateandplacemyapplicationforinsurance.iunderstandthatanyhealthcareproviderwhoreceivesthis authorizationwillnotconditiontreatment,payment,enrollmentoreligibilityforbenefitsonwhetheriprovidethisauthorization. % Signature%of%Proposed%Insured/Guardian%or%Custodian/Authorized%Representative% X PrintedName: Date: %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%THIS%IS%NOT%AN%APPLICATION%FOR%LIFE%INSURANCE% AUTHORIZATION%TO%OBTAIN%AND% DISCLOSE%INFORMATION%