Underwriting Questionnaires

The following questionnaires are intended to help you ask the important questions of your client with medical conditions as part of your fact finding. The more complete these are the better we can help you in setting the proper expectations for your client

Preferred Questionnaire

Informal Application

HIPPA form

Lab results request form

Alcohol Use
Anxiety
Atrial Fibrillation
BPH and Prostate Cancer
Breast Cancer
Build and Blood Pressure
Cancer – general
Chemical Usage
Coronary Artery Disease

Crohn’s Disease
CVA
Depression
Diabetes
Epilepsy
Gastric Bypass
Heart Attack
Heart Murmur
Hepatitis

Hodgkin’s
Leukemia
Liver Disease
Lung Disease
Lupus
Melanoma
Multiple Sclerosis
Myeloma Cancer
Parkinson’s

Prostate Cancer
Racing
Seizure Disorder
Skin Cancer
Sleep Apnea
Stroke
TIA
Ulcerative Colitis