FINAL EXPENSE FORM
Agent Info
Name
Company Name
Address
Email
Phone Number
Client Info
Client Name
State of Residence
DOB
Height / Weight
Gender Male Female
Tobacco Use? YES NO
Amount of final expense coverage being requested:$
Riders Nursing Home Waiver
Accidental Death Benefit Rider
Please answer the questions below so we can provide the best possible final expense premium for your client.

Current medications- Please include why there were prescribed, dosage amount & how long RX has been used
 
Is your client currently bedridden, confined to a nursing facility, hospitalized, receiving hospice care or incarcerated?
  YES NO
Is your client able to perform any Activities of Daily Living (ADL's) such as bathing, eating, and toileting?
  YES NO
If Yes, which ones?
 
Are they currently confined to a wheelchair?
  YES NO
If Yes, Please explain reason and date
 
Is client currently disabled?
  YES NO
If Yes, Please provide reason and date of disability
 
Has your client been medically diagnosed as having a terminal illness or a life expectancy of 12 months or less, Alzheimer 's disease, Dementia or ALS (Lou Gehrig's disease)?
  YES NO
Is your client currently receiving kidney dialysis or using oxygen equipment to assist in breathing?
  YES NO
Has your client ever been diagnosed with Acquired Immune Deficiency Syndrome, or tested positive for HIV (Human Immunodeficiency Virus)?
  YES NO
If under age 25, has your client been diagnosed with cerebral palsy, cystic fibrosis, muscular dystrophy or multiple sclerosis?
  YES NO
Has your client had a heart, lung or liver transplant or has one been recommended?
  YES NO
Have they been advised to have any medical test, hospital, nursing home confinement, psychiatric or home health care and not done so?
  YES NO
In the past 12 months has your client been hospitalized two or more times?
  YES NO
If Yes, Please explain:
 
In the past 5 years has your client been told they have, or been treated for internal cancer, malignant melanoma or leukemia?
  YES NO
If Yes, Please explain:
 

In the past 24 months has your client been diagnosed with, been treated for or taken medication for any of the following conditions:

  • Heart disease including heart attack, heart surgery, heart bypass, congestive heart failure, angioplasty (balloon procedure), stint or heart valve replacement, stroke, aneurysm, angina (chest pain), congestive heart failure, brain tumor?
  • A drug or alcohol dependency/habit or treatment for alcoholism or drug addiction?
  • Complications of diabetes including insulin shock, diabetic coma, amputation caused by disease, blindness or kidney disorder ?
  YES NO
If Yes, Please explain:
 
In the past 24 months has your client been diagnosed, treated for or taken any medications for chronic obstructive pulmonary disease (COPD) which includes emphysema, chronic bronchitis, chronic asthma, black lung, or any other chronic respiratory disorder? In the past 5 years has your client been told they have, or been treated for internal cancer, malignant melanoma or leukemia?
  YES NO
  

 

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