Impaired Risk Questionnaire For Anxiety



Anxiety involves impaired risk underwriting, where a person whose physical condition is less than standard or who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance companies.

Please submit a completed form below to shop for the best possible premium:

* required information        **Please use TAB key to proceed to the next question field, not the ENTER key.**

Agent's Name*:
Phone Number*:
E-Mail Address*:

Applicant's Date Of Birth:

Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Describe condition.
Give the diagnosis, if known.
3. Date of first symptoms?
4. When did your client last see the doctor for this condition?
5. Has your client been hospitalized? Yes No
When (list all)?
6. Is your client taking any medication? Yes No
Name of RX?
7. Is your client employed? Yes No
8. Have mental conditions interfered with your client's work? Yes No
If so, how long?
9. Is your client disabled? Yes No
10. Additional Comments?