Download FIELD UNDERWRITING GUIDE - Berson

Berson-Sokol Agency, Inc.
23500 Mercantile Road, Unit C
Cleveland, OH 44122
Phone: (216) 464-1542
Fax: (216) 464-6522
www.berson-sokol.com
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FIELD
UNDERWRITING
GUIDE
Field Underwriting Guide, Version 2.0
NAILBA COPYRIGHT STATEMENT
IMPORTANT: PLEASE READ BEFORE USE!
The NAILBA Field Underwriting Guide (the “Guide”), © 2007, The National Association of Independent Life
Brokerage Agencies (“NAILBA”). All rights reserved. Only NAILBA, its member agencies, and current exhibitors
are permitted to use and distribute this Guide. The NAILBA membership and current exhibitors are permitted to
add their logo alongside NAILBA’s logo, to the cover page and forms in this Guide without the express and written
concent of NAILBA. Other than this specific modification, no person or entity is permitted to alter, adapt, abridge,
or modify this Guide.
Disclaimer of Liability: With respect to documents and content contained in this Guide, neither NAILBA, nor its
employees or members, makes any warranty, express or implied, or assumes any legal liability or responsibility
for the accuracy, completeness, or usefulness of any information, product, or process disclosed, or represents
that its use would not infringe privately owned rights.
Contact Information:
NAILBA
12150 Monument Drive, Suite 125
Fairfax, VA 22033
E-mail: [email protected] | Phone:(703) 383-3081 | Web site: www.nailba.org
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NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
How to Use This Guide
This NAILBA Field Underwriting Guide had been produced specifically with you, the producer, in mind. We believe
it is a highly unique educational and practical resource that can save you time and earn you more money. The best
practices included here can truly improve your chances of having your business placed quickly and easily!
•
Highlight key points of your app for faster underwriting (click: “Welcome Letter”)
•
Quickly check applications to make sure they are fully complete (click: “Forms Checklist Tool”)
•
Set and manage expectations with your client (click: “Setting Expectations”)
•
Ensure you gather the right information for every case (click: “Quick Fact-Finder Tool”)
•
Understand risk factors and how to optimize the medical assessment process
(click “Generic Underwriting Criteria”)
Created by a group of experienced industry professionals representing each of the entities involved in the
insurance application process, this Guide has been created to be a practical, hands-on resource for you to put
to use as you work through an application. It is also intended to be a long-term reference tool, giving you a full
perspective on the important steps to acknowledge and the distinct roles of the carrier, the Brokerage General
Agency, and you, the producer, in the application process.
Whether you are new to the business or a seasoned veteran to writing apps, we believe this Field Underwriting
Guide can be a great “sidekick” as you seek to improve your production levels. It can be called upon for the
consistency and the competitive edge you need to increase your percentage of successfully written business.
We think that following these guidelines will increase the placement of your business by 10 to 20 percent,
resulting in thousands of additional sales dollars.
New in Version 2.0! – This version of the Guide has been updated from the original published in September 2006
to allow for greater customization and flexibility of use. We encourage you to take advantage of interactive options
such as quick reference links, quick print or e-mail options as well as fill-able forms that you can print and send.
These features are meant to make it easier for you to document your client’s needs right on the spot, giving you
the ability to produce fast and successful applications every time!
This Guide is available for NAILBA members to download and
promote through their agency Web site at www.nailba.org
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
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FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
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NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
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(ASCLIENTHADEITHEROFTHEFOLLOWING (EARTATTACK??????????????????????????????DATE "YPASSSURGERY??????????????????????????????DATE
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FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
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/THERANXIETYDISORDER????????????????????????????????????????????????????????????????????
)NDICATETHENUMBEROFEPISODESANDDATEOFLASTEPISODERECOVERY??????????????????????????????
)SCLIENTONANYMEDICATIONS .O 9ESPLEASEPROVIDENAMEANDDOSAGE?????????????????????????????????????????????????????????????????????????
(ASCLIENTBEENHOSPITALIZEDORSEENINTHEEMERGENCYROOMFORTREATMENTOFANXIETYOROTHERPSYCHIATRICILLNESS .O 9ESPLEASEGIVE
DATESANDLENGTHSOFSTAY???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEAHISTORYOFANYOFTHEFOLLOWINGASSOCIATEDCONDITIONSCHECKALLTHATAPPLY
$EPRESSION 3UICIDALTHOUGHTATTEMPT
3UBSTANCEABUSEALCOHOLORDRUGS
/THERPSYCHIATRICDISORDER????????????????????????????????????????????????????????????????????
)STHECLIENTCURRENTLYWORKING .O 9ESOCCUPATION?????????????????????????????????????????????????????????????????????????????????????
(ASANYTIMEBEENLOSTFROMWORKASARESULTOFCONDITION .O 9ESPLEASEGIVEFULLDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASELISTCURRENTMEDICATIONSINCLUDINGASPIRINACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
!24(2)4)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATTYPEOFARTHRITISISIT%XAMPLERHEUMATOIDOSTEOGOUTYETC
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENWASITINITIALLYDIAGNOSED????????????????????????????????????????????????????????????????????
!RETHEJOINTSINVOLVED .O 9ES
7HATISTHETYPEOFTREATMENTANDDOESITINCLUDECORTISONE
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASELISTCURRENTMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
!42)!,&)"2),,!4)/.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFlRSTDIAGNOSIS?????????????????????????????????
)STHEATRIALlBRILLATIONmUTTER #HRONICPERMANENT 0ROXYSMALINTERMITTENT
!RETHEREANYSYMPTOMSWITHTHEIRREGULARHEARTBEAT
"LACKOUT
$IZZINESSLIGHTHEADEDNESSFAINTFEELING
0ALPITATIONS
#HESTDISCOMFORT
(AVEANYOFTHEFOLLOWINGTESTSBEENDONE)FSOPLEASEGIVEDATEANDRESULTS
%#'?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
3TRESSTEST??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
%CHOCARDIOGRAM???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(OLTERMONITOR?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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#ORONARYHEARTDISEASE !LCOHOL
4HYROIDDISEASE #ARDIOMYOPATHY
-ITRALVALVEDISEASE
5NKNOWN
/THERGIVEDETAILS?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
!6/#!4)/.3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
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&ACE!MOUNT
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)S0OLICYTOBE2EPLACED
-/5.4!).#,)-").'
+INDOFCLIMBING -OUNTAIN 2OCK 4RAIL )CE9EARSOFEXPERIENCE???????????
.UMBEROFCLIMBSINTHELASTMONTHS???????????
#LIMBS/UTSIDETHE#ONTINENTAL53
.UMBEROFCLIMBSINTHENEXTMONTHS???????????
$ATE
#LIMBS)NSIDETHE#ONTINENTAL53
$ATE
5.$%27!4%2$)6).'
(OWLONGHAVEYOUBEENDIVING???????YRS????????MTHS7HATCERTIlCATIONSDOYOUHOLD????????????????????????????????????????????????????
7HATKINDOFEQUIPMENTDOYOUUSE??????????????????????????????????????????????????????$OYOU #AVE 7RECK 3ALVAGEDIVE .O
$IVE$EPTHS
$URINGTHE0AST-ONTHS
#ONTEMPLATEDINTHE.EXT-ONTHS
5NDERFT
FTTOFT
FTORDEEPER
3+9$)6).'
7HATKINDOFLICENSEDOYOUHOLD????????????????????????????????????????????????????(OWMANYJUMPSHAVEYOULOGGED??????????????????????????????
7HATEVENTSDOYOUPARTICIPATEIN0LEASEEXPLAIN?????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OYOUJUMPPROFESSIONALLYORUSEEXPERIMENTALEQUIPMENT0LEASEEXPLAIN????????????????????????????????????????????????????????????????????????????????
.UMBEROFJUMPSINTHELASTMONTHS???????????
.UMBEROFJUMPSINTHENEXTMONTHS???????????
(!.$',)$).'5,42!,)'(4&,9).'!.$(/4!)2"!,,//.3
4YPEOFCRAFTmOWN??????????????????????????????????????????????????????????????4YPEOFTERRAIN??????????????????????????????????????????????????????????????
.UMBEROFmIGHTSINTHENEXTMONTHS???????????????-AXIMUMmIGHTALTITUDE???????????????
$OYOUPARTICIPATEINCOMPETITIVEORSTUNTEVENTS 9ES .O!REYOUALICENSEDPIOLT 9ES .O
7HATCERTIlCATIONSDOYOUHOLD????????????????????????????????????????????????????
7ITHTHEAVOCATIONABOVEDOYOUBELONGTOANYORGANIZEDCLUBS .O 9ESPLEASELIST?????????????????????????????????????????????????????????????
!DDITIONALNOTES?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
"5),$
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
9ES)NCREASE??????LBS$ECREASE??????LBS
.O
(ASCLIENTEVERHADANYWEIGHTREDUCTIONSURGERY .O 9ESPLEASEGIVEDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWING)FANYOFTHELISTEDISCHECKEDOFFREQUESTTHESPECIlCQUESTIONNAIRE
#ORONARYARTERYDISEASE
$IABETES
(IGHBLOODPRESSURE
%LEVATEDCHOLESTEROLORTRIGLYCERIDESLIPID,EVELS
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
(ASASTRESSELECTROCARDIOGRAMTREADMILLTESTBEENCOMPLETEDWITHINTHEPASTYEAR
9ESˆNORMAL$ATE?????????????????????????
9ESˆABNORMAL$ATE?????????????????????????
.O
!RETHEREANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
"5.$,%"2!.#(",/#+
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
0LEASECHECKTYPEOF"""PRESENT
#,""" #2""" ,!("OR,0(" )2""" "IFASCICULARBLOCK
(OWLONGHASTHISABNORMALITYBEENPRESENT?????????YEARS
(ASTHEREBEENANYRECENTCHANGEINTHE%#'
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWINGCHECKALLTHATAPPLY
#HESTPAINORCORONARYARTERYDISEASE
#ARDIOMYOPATHY
(IGHBLOODPRESSURE
#ONGENITALHEARTDISEASE
6ALVULARHEARTDISEASE
(AVEANYCARDIACSTUDIESBEENCOMPLETED
A%XERCISETREADMILLORTHALLIUM .O 9ESˆNORMAL 9ESˆABNORMAL
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)SYOURCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON??????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESYOURCLIENTHAVEANYOTHERMAJORHEALTHPROBLEMSEXCANCERETC .O 9ESPLEASEGIVEDETAILS
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATTYPEOFCANCERWASDIAGNOSED??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTDATEOFlRSTDIAGNOSIS?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)STHEREAFAMILYHISTORYOFCANCER
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(OWWASTHECANCERTREATED
3URGERY #HEMOTHERAPY 2ADIATIONTHERAPY (ORMONALTHERAPY )MMUNOTHERAPY
/THERGIVEFULLDETAILS?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTDATETREATMENTWASCOMPLETED???????????????????????????????????
7HATWASTHESTAGEANDGRADEOFTHECANCER???????????????????????????????????????????????????????
(ASTHEREBEENANYEVIDENCEOFREOCCURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATDIDTHEPATHOLOGYREPORTREVEAL??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATMEDICATIONSISCLIENTTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ",!$$%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
(OWWASTHECANCERTREATEDCHECKALLTHATAPPLY
%NDOSCOPICRESECTIONONLY
%NDOSCOPICRESECTIONANDCHEMOTHERAPYINSTILLEDINTHEBLADDER
2ADICALCYSTECTOMYREMOVALOFTHEBLADDER
2ADIATIONTHERAPY
3YSTEMICCHEMOTHERAPY
7HATSTAGEWASTHECANCER
4IS
4
4A
4
4A
4
4B
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEGIVETHEDATEANDRESULTOFTHEMOSTRECENTCYSTOSCOPYANDURINECYTOLOGY????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATMEDICATIONSISCLIENTTAKINGACCURATENAMEDOSAGEANDREASON?????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED???????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASTHEREBEENANYEVIDENCEOFRECURRENCEIFYESGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYOTHERHEALTHPROBLEMS .O 9ESPLEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ"2%!34
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
(OWWASTHECANCERTREATED
%XCISIONALBIOPSYONLY
,UMPECTOMYORWIDEEXCISION
-ASTECTOMY
2ADIATIONTHERAPY
#HEMOTHERAPY
(ORMONALTHERAPYTAMOXIFEN
,ISTDATETREATMENTWASCOMPLETED???????????????????????????????????
)SCLIENTONANYMEDICATIONS
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATSTAGEWASTHECANCER
3TAGEINSITU 3TAGE) 3TAGE)) 3TAGE))) 3TAGE)6
7ERELYMPHNODESINVOLVED .O 9ES)FYESHOWMANY??????????????????????????
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATEANDRESULTSOFLASTMAMMOGRAM???????????????????????????????????
!RETHEREANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ#%26)#!,
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
7HATSTAGEWASTHECANCER
3TAGEINSITU 3TAGE)A 3TAGE)B 3TAGE)) 3TAGE))) 3TAGE)6
(OWWASTHECANCERTREATEDCHECKALLTHATAPPLY
#ONESURGERY 4OTALHYSTERECTOMY 2ADIATIONTHERAPY #HEMOTHERAPY
)NDICATEDATETREATMENTWASCOMPLETED???????????????????????????????????
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ/6!2)!.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
(OWWASTHECANCERTREATEDCHECKALLTHATAPPLY
3URGERY 2ADIATION #HEMOTHERAPY
7HATSTAGEWASTHECANCER
3TAGE) 3TAGE)) 3TAGE))) 3TAGE)6
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEGIVETHEDATEANDRESULTOFTHEMOSTRECENT#!IFAVAILABLE???????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ02/34!4%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
7HATWASTHEPRETREATMENT03!?????????????????????????????????????????????????????????????????????????????????????????????????????????
(OWWASTHECANCERTREATEDCHECKALLTHATAPPLY
/BSERVATIONONLY 4520TRANSURETHRALPROSTATECTOMY 2ADICALPROSTATECTOMY
2ADIATIONTHERAPYSEEDIMPLANTOREXTERNALBEAMRADIATION
7HATISDATEANDRESULTOFTHEMOSTCURRENT03!TEST????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATWASTHE'LEASONSCORE??????????????????????????
7HATSTATEWASTHECANCER??????????????????????????
)STHEREAFAMILYHISTORYOFCANCER .O 9ES
7HATMEDICATIONSISCLIENTTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ3+).
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATESOFDIAGNOSES???????????????????????????????????
7HATWASTHETYPEOFCANCERWASDIAGNOSED "ASALCELLCARCINOMA 3QUAMOUSCELLCARCINOMA -ALIGNANTMELANOMA
7HEREWASTHESKINCANCERLOCATED???????????????????????????????????
(ASTHECANCERMETASTASIZEDSPREADBEYONDTHESKIN
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
&ORMALIGNANTMELANOMAONLYWHATSTAGEWASTHECANCER
#LARK)INSITU #LARK))"RESLOWMM #LARK)))"RESLOWnMM #LARK)6"RESLOWnMM
#LARK6"RESLOWMM
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#!.#%2ˆ4%34)#5,!2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATESOFDIAGNOSES???????????????????????????????????
7HATWASTHETYPEOFTESTICULARCANCER??????????????????????????????????????????????????????????????????????
)STHEREAFAMILYHISTORYOFCANCER
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(OWWASTHECANCERTREATED 3URGERY #HEMOTHERAPY 2ADIATIONTHERAPY
$ATETREATMENTWASCOMPLETED???????????????????????????????????
7HATSTAGEWASTHECANCER 3TAGE 3TAGE)) 3TAGE)))
(ASTHEREBEENANYEVIDENCEOFRECURRENCE
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEGIVETHEDATEANDRESULTOFTHEMOSTRECENT!&0OR('#TEST????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#%2%"2!,0!,39
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
!TWHATAGEWASITlRSTDIAGNOSED??????????????
)SCLIENTDISABLED
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#(2/.)#/"3425#4)6%05,-/.!29$)3%!3%#/0$
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATISTHETYPEOFLUNGDISEASE
#HRONICBRONCHITIS %MPHYSEMA 2ESTRICTIVELUNGDISEASE !STHMA
$ATElRSTDIAGNOSED???????????????????????????????
(ASYOURCLIENTEVERBEENHOSPITALIZEDFORTHISCONDITION .O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASYOURCLIENTEVERSMOKED
9ESANDCURRENTLYSMOKES??????????????????????AMOUNTPERDAY 9ESSMOKEDINTHEPASTBUTQUIT??????????????????????DATEQUIT
.EVERSMOKED
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
(AVEPULMONARYFUNCTIONTESTSABREATHINGTESTEVERBEENDONE .O 9ESPLEASEGIVEDETAILS????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
#LIENTSBUILD(EIGHT??????????????v7EIGHT??????????????????
$OESYOURCLIENTHAVEANYABNORMALITIESONAN%#'OR8RAY .O 9ESPLEASEGIVEDETAILS?????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESHEARTDISEASEETCADDITIONALQUESTIONNAIRESMAYBEREQUIRED
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#2/(.3$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
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$ATEOFlRSTDIAGNOSIS?????????????????????????????????
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-EDICATIONˆIFSOWHATACCURATENAMEDOSAGEANDREASON
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(OWOFTENDOESCLIENTHAVEATTACKS?????????????????????????????????
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$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#/.'%34)6%(%!24&!),52%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
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&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
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$ATEOFlRSTDIAGNOSIS?????????????????????????????????
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$OESCLIENTHAVEAHISTORYOFANYOFTHEFOLLOWINGPROVIDEDETAILS
(YPERTENSION??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
#ORONARYARTERYDISEASE??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
#HRONICOBSTRUCTIVEPULMONARYDISEASE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ACEMAKER?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASANANGIOGRAMECHOCARDIOGRAMSTRESSTESTORHEARTSCANBEENDONE
.O 9ESPLEASEGIVEDETAILSANDPROVIDEACOPYIFAVAILABLE?????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#/2/.!29!24%29$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATESOFDIAGNOSISANDTYPEOFCORONARYARTERYDISEASE???????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTSFAMILYHAVEANYHISTORYOFHEARTDISEASE .O 9ESLISTFAMILYMEMBERSANDDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTHADANYOFTHEFOLLOWING
(EARTATTACK
$ATE????????????????????????????????????????
#ORONARYANGIOPLASTY04#!
$ATE????????????????????????????????????????
(EARTFAILURE
$ATE????????????????????????????????????????
6ALVESURGERY $ATE????????????????????????????????????????
"YPASSSURGERY
$ATE????????????????????????????????????????
(ASCLIENTHADANYOFTHEFOLLOWING
!BNORMALLIPIDLEVELS
$IABETES
/VERWEIGHT
%LEVATEDHOMOCYSTEINE
(IGHBLOODPRESSURE
0ERIPHERALVASCULARDISEASE
)RREGULARHEARTBEATS
#EREBROVASCULARORCAROTIDDISEASE
%LEVATEDCHOLESTEROL
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#/2/.!29"9P!33
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATESOFDIAGNOSISANDTYPEOFCORONARYARTERYDISEASE???????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTSFAMILYHAVEANYHISTORYOFHEARTDISEASE .O 9ESLISTFAMILYMEMBERSANDDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTHADANYOFTHEFOLLOWING
(EARTATTACK $ATE???????????????????????????
#ORONARYANGIOPLASTY04#!$ATE???????????????????????????
(EARTFAILURE $ATE???????????????????????????
6ALVESURGERY $ATE???????????????????????????
.UMBEROFVESSELSBYPASSED??????????????????
(OWBADLYWERETHEVESSELSOCCLUDEDPERCENTAGE??????????????????
(ASAFOLLOWUPSTRESSEXERCISE%#'BEENCOMPLETEDSINCEPROCEDURE
.O 9ES.ORMAL$ATE???????????????????????????
9ES!BNORMAL$ATE???????????????????????????
(ASCLIENTHADANYCHESTDISCOMFORTSINCETHEPROCEDURE .O 9ESPLEASEPROVIDEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTHADANYOFTHEFOLLOWING
!BNORMALLIPIDLEVELS
)RREGULARHEARTBEATS
(IGHBLOODPRESSURE
$IABETES
%LEVATEDHOMOCYSTEINE /VERWEIGHT %LEVATEDCHOLESTEROL
0ERIPHERALVASCULARDISEASE #EREBROVASCULARORCAROTIDDISEASE
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
#53().'39.$2/-%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATESOFDIAGNOSISANDTYPEOFCORONARYARTERYDISEASE???????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATEVALUATIONWASDONE0LEASEGIVEDATEANDRESULTS
-2)#4
$ATE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
5RINE4EST
$ATE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
"LOOD4EST
$ATE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASYOURCLIENTEVERBEENHOSPITALIZEDFOR#USHINGSYNDROME .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASYOURCLIENTBEENPRESCRIBEDSTEROIDSFORANYOTHERILLNESS .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$%-%.4)!ˆ!,:(%)-%23
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTTHETYPEOFDEMENTIA????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATEOFONSETOFSYMPTOMS????????????????????????????????????$ATEOFDIAGNOSIS????????????????????????????????????
.OTEFUNCTIONALSTATUS
-INIMALCOGNITIVECHANGESFULLYFUNCTIONING
.EEDSSUPERVISIONOUTSIDETHEHOME
!SSISTANCENEEDEDONANY!$,!CTIVITIESOF$AILY,IVING
#USTODIALCARE
)STHEREALSOAHISTORYOFDEPRESSION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$%02%33)/.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTTHEDIAGNOSIS?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEINDICATE.UMBEROFEPISODES???????????????
$ATEOFLASTEPISODE????????????????????????
(ASCLIENTBEENHOSPITALIZEDFORPSYCHIATRICTREATMENT .O 9ESPLESASEGIVEDATESANDLENGTHSOFSTAY
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEAHISTORYOFANYOFTHEFOLLOWINGASSOCIATEDCONDITIONS0LEASECHECKALLTHATAPPLY!DDITIONALQUESTIONNAIRESMAYBEREQUIRED
0ERSONALITYDISORDER
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3UICIDALTHOUGHTATTEMPT
3UBSTANCEABUSEALCOHOLORDRUGSCOMPLETEQUESTIONNAIRE
/THERPSYCHIATRICDISORDER???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)STHECLIENTCURRENTLYWORKING .O 9ESPLEASELISTOCCUPATION
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASANYTIMEBEENLOSTFROMWORKASARESULTOFCONDITION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$)!"%4%3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATElRSTDIAGNOSED????????????????????????????????????
(OWOFTENDOESYOURCLIENTVISITHISHERPHYSICIAN??????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENWASTHELASTVISIT????????????????????????????????????
4HECLIENTSDIABETESISCONTROLLEDBY
$IETALONE
/RALMEDICATIONMEDICATIONANDDOSES?????????????????????????????????????
)NSULINAMOUNTANDUNITSDAY???????????????????????????????????????????????
0LEASEGIVETHEMOSTRECENTBLOODSUGARREADING??????????????????
$OESCLIENTMONITORHISHEROWNBLOODSUGAR??????????????????
)FAVAILABLEPLEASEGIVETHEMOSTRECENTGLYCOHEMOGLOBIN"H!#ORFRUCTOSAMINELEVEL??????????????????????????????????????????
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWING
#HESTPAINORCORONARYARTERYDISEASE
0ROTEININTHEURINE
%LEVATEDLIPIDS
/VERWEIGHT
.EUROPATHY
+IDNEYDISEASE
2ETINOPATHY
!BNORMAL%#' (YPERTENSION
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$/7.39.$2/-%2%4!2$!4)/.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATISAPPLICANTS)1??????????????????
)SAPPLICANTSELFSUPPORTING .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$/7.39.$2/-%
7HATISAPPLICANTSSOCIALANDECONOMICSITUATION
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYCARDIOVASCULARORPULMONARYPROBLEMS .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
2%4!2$!4)/.
!TWHATAGEDIDAPPLICANTBECOMEMENTALLYRETARDED??????????????????
)STHERETARDATIONCHROMOSOMAL .O 9ES0,%!3%02/6)$%!3-5#($%4!),!30/33)",%
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$2)6).'
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
)NTHEPASTYEARSHASCLIENTSDRIVERSLICENSEBEENSUSPENDEDORREVOKED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)NTHEPASTYEARSHASCLIENTBEENCONVICTEDOFORPLEDGUILTYORNOCONTESTTORECKLESSDRIVINGORDRIVINGUNDERTHEINmUENCEOFALCOHOL
ORDRUGS .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATISAPPLICANTSOCCUPATION?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SAPPLICANTMARRIED .O 9ES
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
$25'3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFTHEINITIALTREATMENTORDIAGNOSIS???????????????????????????????????????????????
7HATISCLIENTS
-ARTIALSTATUS????????????????????????????????? /CCUPATION?????????????????????????????????????????? ,ENGTHOFEMPLOYMENT??????????????????
)SCLIENTANACTIVEMEMBEROFADRUGUSERECOVERYGROUP .O 9ESHOWLONG????????????????????
(ASCLIENTEVERJOINEDANDTHENLEFTADRUGUSERECOVERYGROUP .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATDRUGSWEREUSEDORABUSEDNAMEOFDRUGANDDATESOFUSAGE
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7ERETHEREANYRELAPSESFROMSOBRIETYABSTINENCE .O 9ESPLEASELISTDATES
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTEVERBEENCONVICTEDOFANYDRUGRELATEDACTIVITY .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(AVETHEREBEENPHYSICALCOMPLICATIONSORADDITIONALPSYCHIATRICPROBLEMS .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATISCLIENTSCURRENTLEVELOFALCOHOLCONSUMPTION????????????????????
)SCLIENTTAKINGANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
%!4).'$)3/2$%23
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
0LEASEGIVETHEDIAGNOSIS !NOREXIANERVOSA "ULIMIANERVOSA
0LEASEINDICATETHENUMBEROFEPISODESANDDATEOFLASTEPISODERECOVERY
0LEASENOTECLIENTSCURRENT????????????HEIGHT????????????WEIGHT
(ASWEIGHTREMAINEDSTABLEFORATLEASTYEAR .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTBEENHOSPITALIZEDFORTREATMENTOFANEATINGDISORDER .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEAHISTORYOFANYOFTHEFOLLOWINGASSOCIATEDCONDITIONS0LEASECHECKALLTHATAPPLY
3UBSTANCEABUSEALCOHOLORDRUGS0ERSONALITYDISORDER
0SYCHOTICDISORDER3UICIDALTHOUGHTATTEMPT
$EPRESSION!NXIETYDISORDER
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
%-0(93%-!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATISTHECAUSE !STHMA /CCUPATION 3MOKING
7HATISTHEDEGREEOFSEVERITY????????????????????????????????????????
$OESCLIENTUSEOXYGEN .O 9ES
(ASCLIENTEVERBEENHOSPITALIZED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(AVEPULMONARYFUNCTIONTESTSBEENDONE .O 9ESWHATWERETHERESULTS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYRESTRICTIONSOFACTIVITIES .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
%.,!2'%$(%!24
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HENWASTHECONDITIONlRSTDIAGNOSED????????????????????????????????????????
(AVEANYOFTHEFOLLOWINGSYMPTOMSOCCURRED
#HESTDISCOMFORTO
&AINTINGSPELLSORDIZZINESS
3HORTNESSOFBREATH
0ALPITATIONSIRREGULARHEARTBEAT
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWING
#HEST8RAY
.O 9ES.ORMAL 9ES!BNORMAL
%XERCISETREADMILLORTHALLIUM
.O 9ES.ORMAL 9ES!BNORMAL
2ESTINGOREXERCISEECHOCARDIOGRAM
.O 9ES.ORMAL 9ES!BNORMAL
-5'!
.O 9ES.ORMAL 9ES!BNORMAL
#ARDIACCATHETERIZATION
.O 9ES.ORMAL 9ES!BNORMAL
)STHEREAHISTORYOFANYHEARTDISEASEPROBLEMSWITHVALVESCORONARYARTERYDISEASECARDIOMYOPATHYETC
.O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
%0),%039
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFlRSTDIAGNOSIS?????????????????????????????????
)NDICATETHETYPEOFSEIZURE
#OMPLEXPARTIALSEIZURE 4ONICCLONICSEIZURE !BSENSESEIZURE -YOCLONICSEIZURE
)NDICATETHENUMBERORFREQUENCYOFEPISODESANDDATEOFLASTEPISODE????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTBEENHOSPITALIZEDFORTREATMENTOFEPILEPSYGIVEDETAILS
.O 9ESPLEASEGIVEDETAILS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
7HATISCLIENTSOCCUPATION??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
&/2%)'.42!6%,2%3)$%.#%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
0LACEOFBIRTH??????????????????????????????????????????????????????????????#URRENT#ITIZENSHIP???????????????????????????????????????????????????????????????
+INDOF6ISA 0ERMANENT'REEN#ARD 7ORK 3TUDENT /THER0LEASESPECIFY??????????????????????????????????????????????????????????????
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#ITY
#OUNTRY
!RRIVAL$ATE
$EPARTURE$ATE
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#OUNTRY
!RRIVAL$ATE
!DDITIONAL.OTES
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
'%.%2!,53%15%34)/..!)2%
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#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
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02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
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,ISTIMPAIRMENT'IVEASMUCHDETAILASPOSSIBLEINCLUDEWHENTHECONDITIONWASDIAGNOSEDHOWITWASCONTRACTEDANDCURRENTPROGNOSIS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASTHEREBEENANYTREATMENT .O 9ES0LEASEPROVIDESTARTANDENDDATESNAMEOFTREATMENT
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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!CCURATE.AMEOF-EDICATION
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$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
',/-%25,/.%0(2)4)3
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
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0LEASENOTETYPEOF'LOMERULONEPHRITIS????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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7ASAKIDNEYBIOPSYDONE .O 9ESPLEASEGIVEDATEANDDIAGNOSIS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEPROVIDETHECLIENTSMOSTRECENTREADINGSFOR
"LOODPRESSURE????????????????????????????????????????
"5.????????????????????????????????????????????????????
#REATININE?????????????????????????????????????????????
5RINALYSIS?????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(%!24!44!#+ˆ-9/#!2$)!,).&!2#4)/.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATESOFTHEHEARTATTACKS????????????????????????????????????????
(ASTHECLIENTHADANYOFTHEFOLLOWING
%CHOCARDIOGRAM
$ATE????????????????????????????????????????
#ORONARYCATHETERIZATION $ATE????????????????????????????????????????
#ORONARYANGIOPLASTY
$ATE????????????????????????????????????????
"YPASSSURGERY $ATE????????????????????????????????????????
(EARTFAILURE
$ATE????????????????????????????????????????
!RRHYTHMIAS
$ATE????????????????????????????????????????
(ASAFOLLOWUPSTRESSEXERCISE%#'BEENCOMPLETEDSINCETHEHEARTATTACK .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWING
!BNORMALLIPIDLEVELS
)RREGULARHEARTBEATS
/VERWEIGHT
$IABETESAGEOFONSET?????????????
0ERIPHERALVASCULARDISEASE
#EREBROVASCULARORCAROTIDDISEASE
(IGHBLOODPRESSURE
%LEVATEDHOMOCYSTEINE
4HESECONDITIONSREQUIREANADDITIONALQUESTIONNAIRETOBECOMPLETEDPLEASEREQUEST
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(%!24&!),52%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATWASTHECAUSEOFHEARTFAILURE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENWASTHEDIAGNOSISMADE????????????????????????????????????????
(ASCLIENTHADSURGICALHEARTREPAIR .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEAHISTORYOFANYOFTHEFOLLOWINGPLEASEPROVIDEDETAILSORCOMPLETETHEQUESTIONNAIREFORTHECONDITION
(YPERTENSION??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
#ORONARYARTERYDISEASE??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
#HRONICOBSTRUCTIVEPULMONARYDISEASE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ACEMAKER?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASANANGIOGRAMECHOCARDIOGRAMSTRESSTESTORHEARTSCANBEENDONE .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(%!24-52-52
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
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7HATTYPEOFMURMURDOESCLIENTHAVE
!ORTICSTENOSIS
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&LOWMURMUR
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7HENWASTHEHEARTMURMURlRSTDISCOVERED????????????????????????????????????????
$OESCLIENTHAVEAHISTORYOFRHEUMATICFEVER .O 9ES
7HENWASTHECLIENTLASTSEENBYAPHYSICIANFORTHEHEARTMURMUR????????????????????????????????????????
7HENWASTHELASTECHOCARDIOGRAMDONE???????????????????????????????????7HATWERETHERESULTS??????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7ASACARDIACCATHETERIZATIONEVERDONE .O 9ESPLEASEGIVEDATE????????????????????????????????????????
$OESCLIENTHAVEANYSYMPTOMSORANYLIMITATIONOFACTIVITIES .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTHADANYHEARTSURGERYORHASSURGERYBEENDISCUSSED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(%-/#(2/-!4/3)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
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,IVER
0ANCREASDIABETES
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0ITUITARY
7HENWASTHELASTPHLEBOTOMYTREATMENT????????????????????????????????????????
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2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(%0!4)4)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
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(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
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$ATEOFlRSTDIAGNOSIS????????????????????????????????????????
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!343'/4$ATE?????????????????????????? !,43'04$ATE?????????????????????????? ''40$ATE???????????????????????????????
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$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(90%2#/!'5,!",%$)3/2$%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS????????????????????????????????????????
0LEASENOTETYPEOFTREATMENT (OSPITALIZATION$ATE?????????????????????????????
#OUMADIN
!SPIRIN(EPARIN
7ASTHEREATHROMBOEMBOLICEVENT
-)
#6!
$64
0%
/THER
.ONE
(ASTHEREBEENANYEVIDENCEOFRECURRENCE .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(90%2',9#%-)!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS????????????????????????????????????????
7HATWERETHELASTLEVELSFOR
'LYCOHEMOGLOBIN????????????????????????????????????????
'LUCOSE???????????????????????????????????????????????????
-ICROALBUMIN????????????????????????????????????????????
)SCONDITIONCONTROLLED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
(90%24%.3)/.
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS????????????????????????????????????????
7HATWASTHEMOSTRECENTBLOODPRESSUREREADING????????????????????????????????????????
0LEASECHECKANYOFTHEBELOWTHATCLIENTHASHAD
#HESTPAINORCORONARYARTERYDISEASE
$IABETES
&AMILYHISTORYOFHEARTDISEASEHIGHBLOODPRESSURESTROKE
!BNORMALLIPIDLEVELS
4)!ORSTROKE
%NLARGEDHEART
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0ERIPHERALVASCULARDISEASE
+IDNEYDISEASE
/VERWEIGHT
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9ESNORMAL$ATE?????????????????????????
9ESABNORMAL$ATE?????????????????????????
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(ASCLIENTEVERHADANECHOCARDIOGRAM .O 9ES
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!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
)22%'5,!2(%!24"%!4
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
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$ATElRSTDIAGNOSED????????????????????????????????????????
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!RETHEREANYSYMPTOMSWITHTHEIRREGULARHEARTBEAT
"LACKOUT $IZZINESSLIGHTHEADEDNESSFAINTFEELING 0ALPITATIONS #HESTDISCOMFORT
(AVEANYOFTHEFOLLOWINGTESTSBEENDONE)FSOPLEASEGIVEDATEANDRESULTS
%#'
$ATE?????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????
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$ATE?????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????
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$ATE?????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????
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$ATE?????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????
4HECAUSEOFTHEIRREGULARHEARTBEATISDUETO (EARTDISEASE !LCOHOL 4HYROIDDISEASE 5NKNOWNOROTHER???????????????????????
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!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
+)$.%9&5.#4)/.4%343
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATElRSTDIAGNOSED????????????????????????????????????????
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$IABETES
0OLYCYSTICKIDNEYDISEASE
'LOMERULONEPHRITIS
.EPHROSCLEROSIS
3YSTEMICLUPUSERYTHEMATOSUS
/THER????????????????????????????????????????
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"5.???????????????????????????????????????????????????????
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&REQUENTINFECTION
(IGHBLOODPRESSURE
#ARDIOVASCULARDISEASECOMPLETEQUESTIONNAIREFORTHISCONDITION
)SCLIENTONANYMEDICATIONSNOWACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
+)$.%942!.30,!.4
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFTHETRANSPLANT????????????????????????????????????????
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$IABETES
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??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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$OESCLIENTHAVEANYOTHERMAJORHEALTHISSUESADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
,%5+%-)!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
7HATISTHECURRENTSTAGEOFTHELEUKEMIA
3TAGE 3TAGE 3TAGE)) 3TAGE))) 3TAGE)6
0LEASEPROVIDERESULTSOFTHEMOSTRECENT#"#COMPLETEBLOODCOUNT
$ATE??????????????????????????????????????????????????????????????
(EMOGLOBIN?????????????????????????????????????????????????????
7HITEBLOODCELLCOUNT?????????????????????????????????????????
0LATELETCOUNT???????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
,)6%24%343
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
(OWLONGHASTHISABNORMALITYELEVATEDLIVERENZYMESBEENPRESENT?????????????????????????????????????????
0LEASEGIVETHEDATEANDRESULTSOFTHEMOSTRECENTLIVERENZYMETESTS
A!343'/4
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
B!,43'04
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
C''40
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
D!,0
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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$ECREASING
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3TABLE
5NKNOWN
$OESCLIENTDRINKALCOHOLANSWERALLTHATAPPLY
.O 9ESPLEASENOTEAMOUNTANDFREQUENCY????????????????????????????????????????????????????????????????????????????????????
$RINKINGPATTERNCHANGEDRECENTLY?????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
,5.'$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
4YPEOFLUNGDISEASE
)NTERSTITIALLUNGDISEASETYPE????????????????????????????????????????????????????????
#HRONICBRONCHITIS
%MPHYSEMA
!STHMA
7ASABIOPSYDONE .O 9ES
(ASCLIENTIMPROVEDSINCEDIAGNOSIS .O 9ES
(ASCLIENTEVERBEENHOSPITALIZEDFORTHISCONDITION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTEVERSMOKED
9ESCURRENTLYSMOKES????????????????????????AMOUNTDAY
9ESSMOKEDINTHEPASTBUTQUIT???????????????????DATE
.EVERSMOKED
(AVEPULMONARYFUNCTIONTESTSBREATHINGTESTEVERBEENDONE .O 9ESPLEASEGIVEMOSTRECENTTESTRESULTS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
,5053
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
4YPEOFLUPUSDIAGNOSED
3YSTEMICLUPUSERYTHEMATOSUS3,%
$ISCORDLUPUS
$RUGINDUCED3,%
0LEASENOTEIFTHELUPUSIS
INREMISSIONLISTDATEOFLASTEXACERBATION$ATE?????????????????????????????????????????????????????????????????????????????????????????????????????????
CURRENTLYPRESENT
#HECKIFCLIENTHASHADANYOFTHEFOLLOWING
,OWBLOODCOUNTS
.EUROLOGICDISORDER
,UNGINVOLVEMENTPLEURITIS
(EARTINVOLVEMENTPERICARDITIS
0ROTEINURIA
2ENALINSUFlCIENCYORFAILURE
(IGHBLOODPRESSURE
)SCLIENTPRESENTLYONMEDICATIONACCURATENAMEDOSAGEANDREASON .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATTYPEOFTREATMENTHASCLIENTHAD?????????????????????????????????????????????????????????????????????????????
7HENWASTREATMENTTERMINATED?????????????????????????????????????????????????????????????????????????????
(AVESTEROIDSEVERBEENPRESCRIBED .O 9ES
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
,9-0(/-!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSES???????????????????????????????????
)NDICATETHETYPEOFLYMPHOMA
(ODGKINS,YMPHOMA??.ON(ODGKINS,YMPHOMAˆLOWGRADE
.ON(ODGKINS,YMPHOMAˆINTERMEDIATEGRADE
.ON(ODGKINS,YMPHOMAˆHIGHGRADE
7HATWASTHESTAGINGATTHETIMEOFDIAGNOSIS
3TAGE)
3TAGE))
3TAGE)))
3TAGE)6
0LEASENOTEIFANYOFTHEFOLLOWINGWEREPRESENTATTIMEOFDIAGNOSISCHECKALLTHATAPPLY
4YPE"SYMPTOMSFEVERWEIGHTLOSSANDORNIGHTSWEATS
,ARGEMEDIASTINALCHESTDISEASETUMORCM
%LEVATED,$(BLOODTEST
-ORETHANEXTRANODALSITEINVOLVED
7HATTREATMENTDIDCLIENTRECEIVECHECKALLTHATAPPLY
#HEMOTHERAPY 2ADIATION
3URGERY
7HATWASTHEDATEOFTHELASTTREATMENT?????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
-%.4!,$)3/2$%23
")0/,!2$)3/2$%23#():/0(2%.)!%!4).'$)3/2$%230!.)#!44!#+30!2!./)!35)#)$%!44%-043
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ESCRIBECLIENTSCONDITION'IVETHEDIAGNOSIS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATEOFlRSTSYMPTOMS?????????????????????????????????????????????????????????
7HENDIDCLIENTLASTSEEDOCTORFORTHISCONDITION?????????????????????????????????????????????????????????
(ASCLIENTBEENHOSPITALIZED .O 9ESLISTALL
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
)SCLIENTCURRENTLYEMPLOYED .O 9ES
(ASCONDITIONINTERFEREDWITHWORK .O 9ES)FSOHOWLONG????????????????????????????????????????????????????????????????????????????????????
)SCLIENTDISABLED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
-)42!,6!,6%$)3/2$%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
(OWLONGHASTHISABNORMALITYBEENPRESENT????????????????????????????????????????????????????????????????????????????????????
0LEASECHECKTHETYPESOFVALVEDISORDERPRESENT
-ITRALSTENOSIS -ITRALREGURGITATION
-ITRALVALVEPROLAPSE
(AVEANYOFTHEFOLLOWINGOCCURRED
#HESTPAIN
.O 9ES
4ROUBLEBREATHING
.O 9ES
(EARTFAILURE
.O 9ES
0ALPITATIONS
.O 9ES
!TRIALlBRILLATIONmUTTER
.O 9ES
)STHEREAHISTORYOFANYOTHERHEARTDISEASEINADDITIONTOTHEMITRALVALVEDISORDERPROBLEMSWITHOTHERVALVES
CORONARYARTERYDISEASEETC .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(AVEADDITIONALSTUDIESBEENCOMPLETEDCHECKALLTHATAPPLY
%CHOCARDIOGRAM
$ATE??????????????????????????????
#ARDIACCATHETERIZATION
.ONE
$ATE??????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
-)42!,6!,6%02/,!03%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
(OWLONGHASTHISABNORMALITYBEENPRESENT????????????????????????????????????????????????????????????????????????????????????
(AVEANYOFTHEFOLLOWINGSYMPTOMSOCCURREDCHECKALLTHATAPPLY
&AINTINGORDIZZINESS
.O
9ES
0ALPITATIONS
.O
9ES
3HORTNESSOFBREATH
.O
9ES
#HESTPAIN
.O
9ES
)STHEREAHISTORYOFANYOTHERHEARTDISEASEINADDITIONTOTHEMITRALVALVEPROLAPSEPROBLEMSWITHOTHERVALVESCORONARYARTERYDISEASEETC
.O 9ESPLEASESUBMITACOPYOFTHEREPORT
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASANECHOCARDIOGRAMULTRASOUNDOFTHEHEARTBEENDONE .O 9ESPLEASESUBMITACOPYOFTHEREPORT
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
-5,4)0,%3#,%2/3)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATEOFlRSTDIAGNOSIS??????????????????????????????????????????????????
)NDICATENUMBEROFEPISODES??????????????????????????????????????????????????
$ATEOFLASTEPISODE??????????????????????????????????????????????????
0LEASENOTECURRENTNEUROLOGICALSTATUSANDORSYMPTOMS
.ORMAL
-INIMALRESIDUALIMPAIRMENTPLEASESPECIFY???????????????????????????????????????????????????
-ODERATERESIDUALIMPAIRMENTPLEASESPECIFY??????????????????????????????????????????????????
3EVERERESIDUALIMPAIRMENTPLEASESPECIFY?????????????????????????????????????????????????????
7HATARECLIENTSCURRENTSYMPTOMS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATTHERAPYISCLIENTON
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEANYPROBLEMSWITHEXTREMITIESKIDNEYSORBLADDER .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
.%52/-53#5,!2$)3/2$%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTDATEOFlRSTDIAGNOSIS??????????????????????????????????????????????????
.AMEOFNEUROMUSCULARDISORDER??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ESCRIBECONDITIONWITHDIAGNOSIS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATISYOURCONDITION??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTDISABLED .O 9ES
$OESCLIENTUSEACANEORAWHEELCHAIR .O 9ES
$OESCLIENTHAVEACAREGIVER .O 9ES
)SCLIENTRECEIVINGANYTREATMENT .O 9ES7HATTYPE??????????????????????????????????????????????????????????????????????????????????????????
7HENDIDCLIENTLASTSEEDOCTORFORTHISCONDITION??????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0!#%-!+%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATETHEPACEMAKERWASIMPLANTED?????????????????????????????????????????????????
4HEPACEMAKERWASIMPLANTEDFOR
(EARTBLOCKASSOCIATEDWITHCORONARYARTERYDISEASE
#OMPLETEHEARTBLOCKORSICKSINUSSYNDROME
#HRONICUNDERLYINGATRIALmUTTERlBRILLATION
/THERGIVEDETAILS??????????????????????????????????????????????????????????????????????
$OESCLIENTHAVEANOTHERHEARTDISEASE'IVEDETAILS
(AVEANYOFTHEFOLLOWINGPACEMAKERCOMPLICATIONSOCCURRED
)NFECTION
"LOODCLOTS
0ACEMAKERMALFUNCTION
0ERFORATION
/THERPLEASEGIVEDETAILS????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
!RETHEREANYCONTINUINGSYMPTOMSSINCETHEPACEMAKERWASIMPLANTED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENWASCLIENTSLASTCHECKUP?????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0!.#2%!4)4)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
,ISTTHEDATEWHENlRSTDIAGNOSED?????????????????????????????????????????????????
7HATTYPEOFPANCREATICDISORDERWASDIAGNOSED
#YST0SEUDOCYST
!BSCESS
0ANCREATITIS
3TONE
/THERPLEASEGIVEDETAILS????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7ASCLIENTINCAPACITATEDFROMWORKDUETOTHEPANCREATICDISORDER .O 9ESWHENANDFORHOWLONG
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7ASCLIENTHOSPITALIZED .O 9ESGIVEDATESANDHOWLONGBELOW
$ATE??????????????????????????????
$URATION????????????????????????????????????????????????????????????????????????????????????
$ATE??????????????????????????????
$URATION????????????????????????????????????????????????????????????????????????????????????
$ATE??????????????????????????????
$URATION????????????????????????????????????????????????????????????????????????????????????
7ASANYSURGERYPERFORMED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)FPANCREATITISDESCRIBEFREQUENCYOFATTACKSANDDATEOFMOSTRECENTATTACK
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0!.(90/0)45)4!2)3#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HENWASCLIENTDIAGNOSEDWITHPITUITARYDYSFUNCTION????????????????????????????????????????????????
7HATWASTHECAUSEOFTHEPITUITARYDYSFUNCTION??????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATKINDOFHORMONEREPLACEMENTTHERAPYISREQUIRED??????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASELISTDATESOFANYHOSPITALIZATIONSRADIATIONTREATMENTSORSURGERIES)FTHEREWASATUMORPLEASEPROVIDEAPATHOLOGYREPORTANDTHE
RESULTSOFANYSCANS
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0!2!,93)3ˆ3)-),!20(93)#!,$)3!"),)49
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEDISABILITYOCCURED???????????????????????????????????????????????
7HATWASTHECAUSEEGCONGENITALINJURYPOLIO
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATPARTSOFTHEBODYAREAFFECTED
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESCLIENTHAVELIMITATIONSINWALKINGDRIVINGSPEECHOROTHERACTIVITIES .O 9ES
(ASSURGERYBEENPERFORMEDORPLANNED .O 9ES
(ASCLIENTSBOWELORBLADDERFUNCTIONBEENAFFECTED .O 9ES
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0!2+).3/.3$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFlRSTDIAGNOSED?????????????????????????????????????????????????
0LEASENOTETHEFUNCTIONALSTAGEOFTHECLIENTCURRENTLY
3TAGE)
UNILATERALINVOLVEMENT
3TAGE))
BILATERALINVOLVEMENTBUTNORMALSTANCE
3TAGE))
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3TAGE)6
BILATERALINVOLVEMENTWITHPOSTURALINSTABILITYREQUIRESSUBSTANTIALHELP
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(ASTHEREBEENANYEVIDENCEOFPROGRESSION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASENOTEIFANYOFTHEFOLLOWINGHAVEOCCURREDCHECKALLTHATAPPLY
$EMENTIA
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-EMORYPROBLEMS
&ALLS
!SPIRATION
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0NEUMONIA
$EPRESSION
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
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!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0%23/.!,)49$)3/2$%23
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????
0LEASENOTEWHICHTYPEOFPERSONALITYDISORDERHASBEENDIAGNOSED
!NTISOCIAL
.ARCISSISTIC
"ORDERLINE
(ISTRIONIC
0ARANOID
$EPENDENT
3CHIZOID
/BSESSIVE#OMPULSIVE
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!VOIDANT
(ASCLIENTBEENHOSPITALIZEDFORAPSYCHIATRICILLNESS .O 9ESPLEASEGIVEDATESANDDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
$OESYOURCLIENTHAVEANYOFTHEFOLLOWINGASSOCIATEDCONDITIONS
3UBSTANCEABUSEALCOHOLORDRUGS
.O 9ESPLEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????
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.O 9ESPLEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????
3UICIDALTHOUGHTATTEMPT
.O 9ESPLEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????
/THERPSYCHIATRICDISORDER
.O 9ESPLEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????
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!CCURATE.AMEOF-EDICATION
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2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0(%/#(2/-/#94/-!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????
"ENIGNVS -ALIGNANT
3INGLEVS -ULTIPLE
7HATEVALUATIONWASDONE0LEASEGIVEDATEANDRESULTS
-2)#4
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
5RINE4EST
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
"LOOD4EST
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASYOURCLIENTHADSURGERYTOREMOVEAPHEOCHROMOCYTOMA .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
,ISTALLMEDICATIONSCLIENTISTAKINGACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0/,9#934)#+)$.%9$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$OANYOTHERFAMILYMEMBERSHAVE!$0+$ .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7AS!$0+$DIAGNOSEDBYULTRASOUND .O 9ES
7HATAREYOURCURRENTBLOODPRESSUREREADINGS .O 9ES
0LEASEPROVIDETHERESULTSANDDATEOFYOURMOSTRECENTURINALYSIS
0ROTEIN?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
2EDBLOODCELL2"#?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HITEBLOODCELL7"#??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ROTEINCREATININERATIO???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEPROVIDETHEDATEANDRESULTSOFTHEMOSTRECENTKIDNEYFUNCTIONTESTS
"5.
$ATE?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
3ERUM#REATININE $ATE?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
0/,90#93445-/2/2'2/74(
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HATTYPEOFGROWTHDIDCLIENTHAVE???????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENWASITDISCOVERED$ATE??????????????????????????????????????????????
7HATISTHESPECIlCLOCATIONINORONTHEBODYWHEREITISLOCATED
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(OWMANYWEREPRESENTORREMOVED??????????????????????????????????????????????
7HATTYPEOFTREATMENTHASCLIENTHAD?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)FREMOVEDSURGICALLYWHATWASTHEPATHOLOGICALDIAGNOSIS "ENIGN -ALIGNANT
)FYOUHAVEPATHOLOGYREPORTAVAILABLEPLEASEPROVIDEIT
)SCLIENTTAKINGANYMEDICATIONACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
02/34!4%"%.)'."%.)'.02/34!4)#(90%242/0(9!.$02/34!4)4)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEWHENlRSTDIAGNOSED???????????????????????????????????????
)FANYOFTHEFOLLOWINGHAVEBEENDONEPLEASEGIVEDETAILSANDRESULTS
"LADDERCATHETERIZATION???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ROSTATEBIOPSY???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ROSTATEULTRASOUND??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
4520TRANSURETHRALPROSTATECTOMY????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEGIVERESULTANDDATEOFMOSTRECENT03!TEST
$ATE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
02/4%).52)!02/4%).).52).%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
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&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
(OWLONGHASTHISABNORMALITYBEENPRESENT??????????????YEARS
(ASASPECIlCCAUSEFORTHEPROTEINURIABEENFOUND .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
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A0ROTEIN
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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????????????????????????????????????????????????????????????????????????????????????
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????????????????????????????????????????????????????????????????????????????????????
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$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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A-ICROALBUMIN
$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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$ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
CHRCREATININECLEARANCE $ATE??????????????????????????????
????????????????????????????????????????????????????????????????????????????????????
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????????????????????????????????????????????????????????????????????????????????????
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2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
03!ˆ%,%6!4%$
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
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4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
(OWLONGHASTHE03!BEENELEVATED??????????????????????????????
7HATISTHEDIAGNOSIS??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASEGIVETHEDATEANDRESULTSOFALLRECORDED03!VALUES
(AVETHESERESULTSBEEN
)NCREASING
$ECREASING
3TABLE
&LUCTUATINGUPANDDOWN
5NKNOWN
)FANYOFTHEFOLLOWINGHAVEBEENDONEPLEASEGIVETHEDETAILSANDRESULTS
4253??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
03!$??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
&REE03!??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0ROSTATEBIOPSY???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
3!2#/)$/3)3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFlRSTDIAGNOSIS???????????????????????????????????????????????????
7ASABIOPSYDONE .O 9ES
3TAGE???????????????????????????????????????????????????
(OWWASTHESARCOIDTREATED .OTREATMENT 0REDNISONE
$ATETREATMENTWASCOMPLETED???????????????????????????????????????????????????
7HATORGANSWEREINVOLVEDCHECKALLTHATAPPLY
,UNG
+IDNEY
(EART
#ENTRALNERVOUSSYSTEM
,IVERORSPLEEN
3KIN
%YES
,YMPHNODES
'IVERESULTSOFTHEMOSTRECENTPULMONARYFUNCTIONTESTS
&6#??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
&%6??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASTHEREBEENANYEVIDENCEOFRECURRENCEPROGRESSION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
3#,%2/$%2-!#2%34
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
0LEASENOTETYPEOFSCLERODERMA
,OCALIZEDSCLERODERMAMORPHEAORLINEA
,IMITEDSCLERODERMA#2%34
0ROGRESSIVESYSTEMICSCLEROSISDIFFUSESCLERODERMA
0LEASELISTDATEOFlRSTDIAGNOSIS????????????????????????????????????????????????
0LEASECHECKIFCLIENTHASHADANYOFTHEFOLLOWING
7EIGHTLOSS
"ILIARYCIRRHOSIS
(EARTDISEASE
,IVERENZYMEABNORMALITY
,UNGDISEASE
+IDNEYDISEASE
2EYAUDSDISEASE
4ROUBLESWALLOWING
0LEASELISTFUNCTIONALABILITY
&ULLYACTIVE
3EDENTARY
5SESWALKERCANEETC
5SESWHEELCHAIR
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
3%):52%$)3/2$%2%0),%039
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFlRSTDIAGNOSIS???????????????????????????????????????????????????
7HENDIDCLIENTHAVETHElRSTANDLASTATTACK?????????????????????????????????????????????????????????????
!RETHEATTACKS GRANDMALOR PETITMALINCHARACTER
7HATISTHEFREQUENCYOFTHEATTACKS????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATTYPEOFTREATMENTISINDICATED????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENDIDCLIENTLASTSEEHISHERPHYSICIANFORTHISCONDITION
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATISCLIENTSOCCUPATION
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
3)#+,%#%,,!.%-)!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????????
7HATTYPEOFSICKLECELLANEMIADOESCLIENTHAVE
3ICKLECELL33
3ICKLECELL3#
3ICKLECELLTRAIT3!
(EMOGLOBIN#
)STHEREAHISTORYOFCOMPLICATIONS .O 9ESPLEASECHECKTHOSETHATAPPLYANDGIVETHEDATEOFTHELASTEPISODE
0AINFULCRISIS
$ATE??????????????????????????????
!ASEPTICNECROSISOFBONES $ATE??????????????????????????????
,EGULCERS
$ATE??????????????????????????????
,UNGSCARRING
$ATE??????????????????????????????
4HROMBOSIS
$ATE??????????????????????????????
%NLARGEDHEART
$ATE??????????????????????????????
/THER??????????????????????????$ATE??????????????????????????????
7HATISTHECURRENTHEMOGLOBIN???????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
3,%%0!0.%!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????????
7ASTHESLEEPAPNEADIAGNOSEDAS
/BSTRUCTIVE
#ENTRAL
-IXED
5NKNOWN
(OWISTHESLEEPAPNEABEINGTREATED
/BSERVATIONALONE
7EIGHTLOSS
#0!0MASKIF#0!0GIVENDATEUSEWASTERMINATED??????????????????????????????????????
3URGERY$ATEOFSURGERY??????????????????????????????????????
/THERPLEASEGIVEDETAILS????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)FSURGERYWASDONEWASSLEEPAPNEACORRECTED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASCLIENTHADANYOFTHEFOLLOWING
LUNGDISEASE
OVERWEIGHT
CHESTPAINORCORONARYARTERYDISEASE
DEPRESSION
STROKE
ARRHYTHMIA
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
30).!,#/2$).*5290,%')#
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????????
!TWHATSPINALCORDLEVELWASTHEINJURYLISTSPECIlCVERTEBRAEIFAVAILABLE
#ERVICALSPINE
???????????????????????????????????????????????????
4HORACICSPINE
???????????????????????????????????????????????????
,UMBROSACRALSPINE ???????????????????????????????????????????????????
.OTECURRENTLEVELOFFUNCTION
)NCOMPLETEPARAPLEGIA
#OMPLETEPARAPLEGIA
)NCOMPLETEQUADRIPLEGIA
#OMPLETEQUADRIPLEGIA
(AVEANYOFTHEFOLLOWINGOCCURREDCHECKALLTHATAPPLY
0NEUMONIA
3KINULCERS
5RINARYTRACTINFECTION
+IDNEYIMPAIRMENT
$EPRESSION
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
34%.4
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HENANDWHEREWASTHESTENTPUTIN?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATTYPEOFSTENTWASPUTIN??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HYWASTHESTENTPUTIN???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(OWMANYVESSELSWEREINVOLVED?????????????????????????????????????????????????????????
(ASTHEAPPLICANTHADANIMAGEDSTRESSTESTDONE .O 9ESIFYESWHENANDWHATWERETHERESULTS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HATTYPEOFFOLLOWUPTESTINGHASBEENDONEANDWHATWERETHERESULTS?????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7ASTHEREAHEARTATTACKPRIORTOTHESTENTBEINGPUTIN .O 9ES
)STHEREFAMILYHISTORYOFHEARTDISEASE .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
342/+%4)!
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATESOFTHEEPISODES?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7EREANYOFTHEFOLLOWINGSTUDIESCOMPLETED
#AROTIDULTRASOUND
$ATE??????????????????????????????
(EAD#4SCANOR-2)SCAN
$ATE??????????????????????????????
%CHOCARDIOGRAM
$ATE??????????????????????????????
7ASCLIENTHOSPITALIZED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
7HENDIDCLIENTLASTSEETHEIRDOCTORFOREVALUATION??????????????????????????????????????????????????????????????
0LEASECHECKANYOFTHEOFTHEFOLLOWINGTHATYOURCLIENTHASHAD
ELEVATEDCHOLESTEROL
3TROKE
DIABETES
HIGHBLOODPRESSURE
PERIPHERALVASCULARDISEASE
HEARTATTACK
CORONARYARTERYDISEASE
(ASSURGERYEVERBEENDONEONANYCAROTIDARTERYIES .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
'IVETHEDATEANDRESULTOFTHEMOSTRECENTBLOODPRESSUREREADINGS$ATE??????????????????????????????
????????????????????????????????????????????
!RETHEREANYRESIDUALSLIMITATIONOFMOVEMENTSPEECHORVISION .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
47!6%#(!.'%3
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
(OWLONGHASTHISABNORMALITYBEENPRESENT??????????????????????????????????????????????????????????
(ASTHEREBEENANYRECENTCHANGEINTHE%#'LASTMONTH .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
0LEASECHECKIFYOURCLIENTHASHADANYOFTHEFOLLOWINGCHECKALLTHATAPPLY
A#HESTPAINCORONARYARTERYDISEASEOROTHERCARDIOVASCULARIMPAIRMENT .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
BDIABETES
.O 9ES
CELEVATEDCHOLESTEROL
.O 9ES
DHIGHBLOODPRESSURE
.O 9ES
(AVEANYOTHERSTUDIESBEENCOMPLETED
AEXERCISETREADMILLORTHALLIUM
.O 9ESNORMAL 9ESABNORMAL
BRESTINGOREXERCISEECHOCARDIOGRAM .O 9ESNORMAL 9ESABNORMAL
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
4(2/-"53(90%2#/!'5,!",%#,/44).'$)3/2$%2
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????????
.OTETHETYPEOFTREATMENT
#OUMADIN
!SPIRIN
(EPARIN
(OSPITALIZATION$ATE??????????????????????????????
7ASTHEREA4HROMBOEMBOLICEVENT
-)
$64
#6!
0%
/THER???????????????????????????????????????????????????
.ONE
(ASTHEREBEENANYEVIDENCEOFRECURRENCE .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
4(92/)$$)3%!3%
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
$ATEOFDIAGNOSIS???????????????????????????????????????????????????
7ASTHETHYROIDDISEASEDIAGNOSEDASMORETHANONEISPOSSIBLE
'OITER
4HYROIDNODULE
(YPERTHYROIDISM
(YPOTHYROIDISM
(OWISTHETHYROIDDISEASEBEINGTREATED
3URGERY
2ADIOACTIVEIODINE
-EDICATION
0LEASEGIVEDETAILS???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
(ASABIOPSYORlNENEEDLEASPIRATION&.!BEENDONE .O 9ESPLEASEPROVIDEACOPYOFTHEREPORT
(ASCLIENTHADANULTRASOUNDORRADIOACTIVESCANOFTHETHYROID .O 9ESPLEASEPROVIDEACOPYOFTHEREPORT
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________
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NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
6!,65,!2(%!24352'%29
#,)%.4.!-%??????????????????????????????????????????????????????????????????????????????????????????????????????$ATE??????????????????????????????????
-ALE &EMALE$ATEOFBIRTH??????????????????(EIGHT??????????????v7EIGHT??????????????????
4OBACCO5SE .EVERUSED 4OTALLYSTOPPED$ATESTOPPED?????????????????? 5SENOW4YPEOFNICOTINEPRODUCT?????????????????????
4YPEOF#OVERAGE 4ERM 5, 3URVIVOR4YPEOF#OVERAGE 4ERM 5, 3URVIVOR5,
#OVERAGE!MOUNT????????????????????????????????????!NTICIPATED0REMIUM?????????????????????????????????????
&!-),9()34/29
(ASPROPOSEDINSUREDHADAPARENTBROTHERORSISTERWHOHADCANCERDIABETESSTROKEHEARTORKIDNEYDISEASEORWHOCOMMITTEDSUICIDE
)FYESUSESEPARATESHEETTOPROVIDETHISINFORMATIONINCLUDINGAGEOFONSETANDDATEOFDEATH
02/0/3%$).352%$3%8)34).').352!.#%
&ULL.AMEOF#OMPANY
&ACE!MOUNT
9EAR)SSUED
)S0OLICYTOBE2EPLACED
7HENWASTHESURGERYCOMPLETED???????????????????????????????????????????????????
0LEASENOTETYPEOFVALVESURGERY
6ALVEREPLACEMENT
6ALVULOPLASTY
#OMMISSUROTOMY
/THER???????????????????????????????????????????????????
0LEASECHECKTHETYPESOFVALVEDISORDER
!ORTICSTENOSIS
-ITRALSTENOSIS
!ORTICINSUFlCIENCY
-ITRALINSUFlCIENCY
-ITRALVALVEPROLAPSE
0LEASENOTETYPEOFVALVEUSEDIFREPLACED
0ROSTHETICMECHANICAL
4ISSUEPORCINEORPIG
(AVEANYOFTHEFOLLOWINGOCCURRED
#HESTPAIN
(EARTFAILURE
0ALPITATIONS
$IZZINESSFAINTING
4ROUBLEBREATHING
)STHEREAHISTORYOFANYOTHERDISEASEINADDITIONTOTHEVALVEDISORDERCORONARYARTERYDISEASEETC .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
)SCLIENTTAKINGANYMEDICATIONINCLUDINGINHALERSACCURATENAMEDOSAGEANDREASON
!CCURATE.AMEOF-EDICATION
$OSAGE
2EASON
!RETHEREANYOTHERHEALTHPROBLEMSADDITIONALQUESTIONNAIRESMAYBEREQUIRED .O 9ESPLEASEGIVEDETAILS
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
.!),"!&IELD5NDERWRITING'UIDE6ERSION\¥#OPYRIGHT!UGUST4HE.ATIONAL!SSOCIATIONOF)NDEPENDENT,IFE"ROKERAGE!GENCIES.!),"!!LLRIGHTSRESERVED
FAMILY HISTORY (ADDENDUM)
CLIENT NAME: ______________________________________________________________________________________________________
Male
Female Date of birth: __________________ Height: _______’ _______” Weight: __________________
Date: __________________________________
1. Has the proposed insured had relative(s) with any of the following:
Parent
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Brother
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
Sister
Has had:
Cancer
Diabetes
Stroke
Heart disease
Committed suicide
Other (explain below)
Age of onset: ____________________ Date of death: ____________________
2. If yes to any of the above, please provide details/information
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
Authorization to Release Results
October 1, 2007
To: (Carrier Name and Address)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
From: (Client Name and Address)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
RE:
Date of Birth:
File Number: __________________________
Social Security #:
___________________________________________
___________________________________________
Please fax my insurance exam, lab results (blood and urinalysis), and resting EKG to me at:
Fax: ________________________________________________________________________________________________
Phone: _____________________________________________________________________________________________
Thank you for your prompt attention to my request.
Sincerely,
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.
114
!UTHORIZATIONFOR2ELEASEOF)NFORMATIONn3!-0,%/.,9
./4%#/.4!#49/52!'%.#9&/2!'%.#9!002/6%$()0!!&/2&ORTHEPURPOSEOFOBTAININGTHEINSURANCECOVERAGETHAT)HAVE
REQUESTED ) HEREBY AUTHORIZE 9/52 !'%.#9 (%2% AND ITS AF
lLIATED AGENCIES TO DISCLOSE MY PERSONAL lNANCIAL AND HEALTH
INFORMATIONTOTHEINSURANCECOMPANIESLISTEDBELOW
4HISAUTHORIZATIONSHALLBEVALIDFORTWELVEMONTHSFROMTHE
DATEBELOW!COPYOFTHISAUTHORIZATIONSHALLBEASVALIDASTHE
ORIGINAL)UNDERSTANDTHAT)AMENTITLEDTORECEIVEACOPYOFTHIS
AUTHORIZATION
)AUTHORIZEANYHEALTHPLANPHYSICIANHEALTHCAREPROFESSIONAL
HOSPITALCLINICLABORATORYPHARMACYMEDICALFACILITY0HARMACY
"ENElT-ANAGEROROTHERHEALTHCAREPROVIDERTHATHASPROVIDED
TREATMENTORSERVICESTOMEORONMYBEHALFWITHINTHEPAST
YEARShMY0ROVIDERSvTODISCLOSEMYENTIREMEDICALRECORDAND
ANYOTHERINFORMATIONTHATMAYBECONSIDEREDPROTECTEDHEALTH
INFORMATIONUNDERTHE(EALTH)NSURANCE0ORTABILITYAND!CCOUNT
ABILITY!CTOFh()0!!vCONCERNINGMETOMY2EPRESENTA
TIVEANDITSSTAFFAFlLIATEDCOMPANIESANDORENTITIESINSURANCE
COMPANIES AND THEIR REINSURERS 4HIS INCLUDES INFORMATION ON
THE DIAGNOSIS OR TREATMENT OF (UMAN )MMUNODElCIENCY 6IRUS
()6 INFECTION AND SEXUALLY TRANSMITTED DISEASES 4HIS ALSO
INCLUDES INFORMATION ON THE DIAGNOSIS AND TREATMENT OF MENTAL
ILLNESSANDTHEUSEOFALCOHOLDRUGSANDTOBACCOBUTEXCLUDES
PSYCHOTHERAPYNOTES
)UNDERSTANDTHAT)MAYWRITETOMY2EPRESENTATIVETOREVOKETHIS
AUTHORIZATION AND THAT THE REVOCATION WILL TAKE EFFECT WHEN MY
2EPRESENTATIVE RECEIVES MY WRITTEN REQUEST ) UNDERSTAND THAT
ANYACTIONALREADYTAKENINRELIANCEONTHISAUTHORIZATIONCANNOT
BE REVERSED AND MY REVOCATION WILL NOT AFFECT THOSE ACTIONS )
UNDERSTANDTHATTHEMEDICALPROVIDERTOWHOMTHISAUTHORIZATION
ISFURNISHEDMAYNOTCONDITIONITSTREATMENTOFMEONWHETHEROR
NOT)SIGNTHEAUTHORIZATION
"YMYSIGNATUREBELOW)ACKNOWLEDGETHATANYAGREEMENTS)HAVE
MADEWITHMY0ROVIDERSTHATRESTRICTDISCLOSUREOFMYMEDICAL
RECORDSANDANYASSOCIATED()0!!PROTECTEDHEALTHINFORMATION
DONOTAPPLYFORPURPOSESOFTHISAUTHORIZATIONAND)INSTRUCTMY
0ROVIDERSTORELEASEANDDISCLOSEMYENTIREMEDICALRECORDWITH
OUTRESTRICTIONTO9/52!'%.#9(%2%)UNDERSTANDTHATANY
INFORMATIONTHATISDISCLOSEDPURSUANTTOTHISAUTHORIZATIONMAY
BE REDISCLOSED AND NO LONGER COVERED BY CERTAIN FEDERAL RULES
GOVERNINGPRIVACYANDCONlDENTIALITYOFHEALTHINFORMATION
4HEINFORMATIONCONTAINEDINTHESEMEDICALANDlNANCIALRECORDS
WILLBEHELDINCONlDENCEANDMAYBEUSEDONLYFORTHEPURPOSE
OF THE PROCUREMENT OR THE EVALUATION OR UNDERWRITING FOR THE
POSSIBLE PROCUREMENT OF LIFE HEALTH LONG TERM CARE OR OTHER
INSURANCEPRODUCTS4HECONTENTSTHEREINMAYBEREVIEWEDAND
ASSESSEDBYAQUALIlEDSTAFFCONSISTINGOFMEDICALDIRECTORSUN
DERWRITERSUNDERWRITINGASSISTANTSOROTHERRELATEDEMPLOYEES
INVOLVED IN THE SUBMISSION RECEIPT OR EVALUATION OF INSURANCE
APPLICATIONSORPROSPECTIVEAPPLICATIONSOFTHEINSURANCECOMPA
NIESLISTEDBELOWANDTHEIRREINSURERSASWELLAS9/52!'%.#9
(%2%ANDITSSTAFFEMPLOYEESANDAFlLIATEDCOMPANIES
) UNDERSTAND THAT IF ) REFUSE TO SIGN THIS AUTHORIZATION 9/52
!'%.#9(%2%MAYNOTBEABLETOPROVIDEFULLANDCOMPLETEIN
FORMATIONABOUTTHEINSURANCECOVERAGEANDITSCOSTTHATMAYBE
AVAILABLETOME)ALSOUNDERSTANDANDACKNOWLEDGETHATEACHOF
THEINSURERSLISTEDONTHISFORMORTOWHICH)MAYFORMALLYAPPLY
MAYREQUIREMETOSIGNASIMILARAUTHORIZATIONUSEDEXCLUSIVELY
BYSUCHINSURERBEFORETHEYWILLPROCESSMYAPPLICATIONOROFFER
INSURANCECOVERAGE)UNDERSTANDTHATMY0ROVIDERSMAYNOTRE
FUSETOPROVIDETREATMENTORPAYMENTFORHEALTHCARESERVICESIF)
REFUSETOSIGNTHISAUTHORIZATION
02/0/3%$).352%$3.!-%
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3)'.%$!.$$!4%$/.!4#)4934!4%:)0#/$%
!'%.47)4.%33
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ACKNOWLEDGMENTS
NAILBA offers our sincerest gratitude to the members of the Field Underwriting Subcommittee
which was formed as a component of the NAILBA Application Pipeline Committee. Without their
time and resources, this Guide would have not been able to be produced.
Name
Organization
Grant Andrew
Pam Anson
Kim Boyer
Wendy Brewer
Barry Cook
Stacey Gabaldon (Chairperson)
Cindy Gentry (Chairperson)
Bill Hunter
Jeff Lingenfelter
Paul Mickus
Meg Rose
Yvette Saenz
Beth Zervas
Prudential
ING
The National Benefit Corporation
designBOX
New York Life
E–Z Data, Inc.
Brown and Brown Associates, P.C.
iPipeline
Lincoln Benefit Life
PixelPoint Design & Production, LLC
NAILBA
Capital Aspects
Zenith Marketing Group
Special thanks go to Beth Zervas and Kim Boyer for their efforts in developing the comprehensive
Medical Impairments section of this Guide. We would also like to thank the following members of the
NAILBA Community for their contributions and permission to their forms and content in this piece:
Name
David Long
Michael Tessler
Victoria “Tori” Van Dusen-Roos
Becky Wingate
Organization
CPS Sacramento/Long Insurance Services
Brokerage Unlimited
Diversified Brokerage Services
LifeMark Partners
This Guide is available for NAILBA members to download at www.nailba.org
116
NAILBA Field Underwriting Guide, Version 2.0 | © Copyright August 2007. The National Association of Independent Life Brokerage Agencies (NAILBA). All rights reserved.