Quick Quote Impaired Risk Review Request
Agent Information
Agent Name
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Agent Email
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Agent Phone Number
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Client Information
Client Initials
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Client Current Age
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Client Birth Month
Gender
Height
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Weight
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Smoker
If No on Smoker, Date last used if ever.
MM
/
DD
/
YYYY
Medical Impairments (please be as detailed as possible)
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Non-Medical Concerns (Scuba Diving, Pilot, etc.)
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Family History (Parents, Siblings)
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Medications (Reason for Rx, dosages)
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Actions from other carriers
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Case Concerns - (health issues, tobacco usage, family history, driving record...etc)
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Desired Product Type and Face Amount
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