Informal Review Submission

Step 1 of 6 - HIPAA Authorization

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HIPAA Authorization

To process your request, we require a signed HIPAA Authorization form. Please download the form, sign it, and then upload the completed document in the field below.

Download HIPAA Authorization Form

HIPAA Authorization Submission(Required)

Please upload your completed HIPAA Authorization Form as required. Prior to uploading, please ensure that all sections in the form have been filled out and signed.

Max. file size: 50 MB.

Advisor Information

Agent Name(Required)

First Last

Agent's Phone Number(Required)

Agent's Fax Number

Agent's Email Address(Required)

Client Information

Client Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Gender

Social Security Number(Required)

Citizenship Status(Required)

Please indicate your visa type and its expiration date:(Required)

(e.g. Visa Type: H-1B + Expiration Date: 8/15/27)

Please indicate if you intend to remain in the United States indefinitely:(Required)

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status

Insurance Plan Information

Plan of Insurance / Amount Desired:

How much Life Insurance currently In Force?

Leave blank if there is no coverage in place

Premium Tolerance:

Has this case been submitted to other companies within the past 6 months?

Yes

Prior Plan Submissions(Required)

If Case has been previously submitted within 6 months, complete the fields below. Click the "+" button to add additional rows.

Company

File #

Date

Have you ever applied for or been issued insurance coverage that was rated or issued other than as applied?

Yes

Rated or Issued Coverage Details(Required)

Click the "+" button to add additional rows.

Name of Company

Amount

Year

Issued

Standard Premium

Extra Premium

Reason Rated or Declined(Required)

Please explain the reason for the rating or declination of the coverage mentioned above.

General Health Information

Height(Required)

(e.g., 5'10" or 178 cm)

Weight(Required)

(e.g., 150 lbs or 68 kg)

Have you experienced any weight loss in the past 12 months?(Required)

Yes

Please specify the amount of weight lost in the last 12 months:(Required)

(e.g. 10 pounds)

Family Health History

Please provide health details for each immediate family member. Include age if living, current health status, age at death (if deceased), and cause of death. Click the "+" button to add additional rows.

Immediate Family Member

Living or Deceased

Age (Current or Age of Death)

Current Health/Cause of Death

Physician and Healthcare Facility History (Last 10 Years)(Required)

Please list all physicians you have consulted, as well as any hospitals, clinics, or other medical facilities where you have received treatment in the past 10 years. Click the "+" button to add additional rows.

Physician Name

Hospital/Clinic Name

Phone Number

Address

Date of Visit

Reason for visit:

Please list all medications you are currently taking:

Click the "+" button to add additional rows.

Name of Medication (Prescription or Otherwise)

Dates Used

Quantity Taken

Frequency Taken

Have you ever been diagnosed with any of the following?

(Select all that apply)

Arthritis

Asthma

Cancer

Cardiovascular

Diabetes

Hepatitis

Multiple Sclerosis

Pancreatis

Polycystic Kidney Disease

Sarcoidosis

Sleep Apnea

Stroke

Substance Use

Other Medical Condition

Do you currently use, or have you ever used Tobacco/Nicotine/Vaping Products/Cessation Aids?(Required)

Yes

Please provide the Type of Product, Details, Frequency and Date of Last Use(Required)

Click the "+" button to add additional rows.

Type of Product

Details

Frequency of Use

Date of Last Use (if applicable)

Do you currently use, or have you ever used Marijuana?(Required)

Yes

Was the Marijuana used for medical purposes?(Required)

Yes

If so, do they have a prescription card? What condition are they treating?(Required)

Please provide the Form of Marijuana, Details, Frequency and Date of Last Marijuana Use(Required)

Click the "+" button to add additional rows.

Form of Marijuana

Details

Frequency of Use

Date of Last Use (if applicable)

Is there any additional information about your medical history that you believe is important for underwriting purposes?

Hazardous Activities / Foreign Travel

Please select all activies/travel applicable to you:

Scuba Diving

Mountain Climbing

Bungee Jumping

Hang Gliding

Ultralight Flying

Auto/Motorcycle Racing

Sky Diving

Travel

Please provide additional detail for "Future Travel":

Arthritis

Date of Diagnosis:

Month

Day

Year

What type of arthritis has been diagnosed?

Which tissues have been involved?

Joints

Heart

Lungs

Central Nervous System

Other

Please specify which joints have been affected:

Please describe any other tissues involved:

Has the condition ever completely disappeared?

Yes

When did it disappear?

Month

Day

Year

If the condition has ever disappeared, has it relapsed?

Yes

Please provide approximate dates of when it resolved and when it reoccurred:

Additionally, indicate any known factors that may trigger onset or contribute to remission (e.g., changes in climate, location, etc.).

Please list any other medical information that may help provide a more realistic preliminary assessment:

Asthma

Date of Diagnosis:

Month

Day

Year

What type of asthma has been diagnosed?

Do you know what leads to the asthmatic attacks?

Yes

Please describe what triggers your asthma attacks:

Please describe the frequency of attacks and how often they have occurred:

During the past year

During the past 2 years

During the past 3 years

4 years or more

Past 12 Months

Please provide number of attacks per year:

Past 2 years

Please provide number of attacks per year:

Past 3 years

Please provide number of attacks per year:

Past 4 or more years

Please provide number of attacks per year:

Have you ever been hospitalized due to severe asthma attacks?

Yes

Please provide details about your hospital stay:

Click the "+" button to add additional rows.

Date(s) of Hospitalization

How long were you in the hospital?

Were there any special circumstances?

Cancer

Exact Name and Location of Cancer:

Date of Diagnosis:

Month

Day

Year

Stage and Grade:

How has the cancer been treated?

Surgery

Radiation

Chemotherapy

Hormone Therapy

Immunotherapy

Observation Only

Please indicate who has the pathology report:

Dates and details of cancer treatment/surgery:

Cardiac

Have you ever had:

Chest Pain

Palpitations

Fluttering or skipping of the heart

Shortness of Breath

Heart attack or heart failure

Coronary Artery Bypass Graft (CABG)

Angioplasty or balloon angioplasty

Stent placement

Heart Catheterization

Heart studies due to symptoms or family history

If you required bypass, angioplasty, or stenting please confirm the arteries involved.

(e.g. Stent Placement: Right Coronary Artery (RCA) – one stent placed)

When did the above event occur and was there only one event?

(e.g. Shortness of Breath: First episode 03/2023 – Occurred intermittently with exertion)

Diabetes

Type of Diabetes Diagnosis:

(e.g. Type 1, Type 2, Gestational)

Date of Diagnosis:

Month

Day

Year

Hemoglobin A1C Result (At Time of Diagnosis):

Hemoglobin A1C Result (Most Recent):

Do you regularly test your Blood Glucose?

Yes

Results:

Frequency:

Have you been diagnosed with having Protein and/or Microalbumin in your Urine:

Yes

Diabetes Treatment History:

Please provide details of your current and past diabetes treatments, including medications, lifestyle changes, and insulin use, with type, duration, and any relevant notes.

Hepatitis

Date of Diagnosis:

Month

Day

Year

What type of Hepatitis?

Was the Hepatitis due to:

Hepatitis A

Hepatitis C (non-A/non-B)

Hepatitis B (resolved)

Hepatitis B (carrier or chronic infection)

Other

Other, please specify:

AST/SGOT Testing

Please provide the date and results of the most recent liver function (enzyme) tests as applicable

Test Date

Results

ALT/SGPT Testing

Please provide the date and results of the most recent liver function (enzyme) tests as applicable

Test Date

Results

GGTP Testing

Please provide the date and results of the most recent liver function (enzyme) tests as applicable

Test Date

Results

Do you consume alcohol?

Yes

How many times per week do you consume Alcohol?

Have any of the following studies have been completed?

Liver Ultrasound or CT Scan

Liver Biopsy

No further evaluation

Scan Results:

Normal

Abnormal

Biopsy Results:

Normal

Abnormal

Have you been diagnosed with any of the following?

Chronic Hepatitis

Cirrhosis

When did the treatment start?

Month

Day

Year

When did the treatment end?

Month

Day

Year

Was treatment successful in eliminating the virus?

Yes

Multiple Sclerosis (MS)

Date of First Diagnosis:

Month

Day

Year

Date of Last Diagnosis:

Month

Day

Year

Number of episodes:

Current neurologic status and/or symptoms:

Normal

Minimal residual impairment

Moderate residual impairment

Severe residual impairment

Please specify:

Please provide details of all brain MRI scan reports:

Pancreatitis

Date of First Diagnosis:

Month

Day

Year

What type of pancreatic disorder was diagnosed?

Cyst/Pseudocyst

Abscess

Pancreatitis

Stone

Other

Other:

If pancreatitis, describe frequency of attacks and date of most recent attack:

Were you incapacitated from work due to the pancreatic disorder?

Yes

Please detail how long you were out of work:

Were you hospitalized?

Yes

Hospitalization Details:

Click the "+" button to add additional rows.

Dates

Duration

Was any surgery performed?

Yes

Please provide details of surgery:

Polycystic Kidney Disease

Do any other family members have ADPKD?

Yes

If so, please provide detail:

Was your ADPKD diagnosed by ultrasound?

Yes

What are your current blood pressure readings?

Please provide the results and date of your most recent urinalysis:

Protein:

Red Blood Cell (RBC):

White Blood Cell (WBC):

Protein/Creatinine ratio:

Please provide the date and results of the most recent BUN test:

Date:

Result:

Please provide the date and results of the most recent Serum Creatinine test:

Date:

Result:

Sarcoidosis

Date of First Diagnosis:

Month

Day

Year

How was the sarcoidosis diagnosed?

(e.g. by x-ray)

Was the condition staged?

Yes

Please list stage:

Describe current symptoms, if any:

Was there (is there) any treatment for this condition?

Yes

Date of last treatment:

Month

Day

Year

Please describe treatment:

Has there been any organ involvement?

Yes

Please list the organs involved:

Has there ever been a reccurence?

Yes

Please list approximate dates of any recurrent episodes:

Click the "+" button to add additional rows.

Please provide the results of the most recent pulmonary function tests, if available:

FVC:

FEV1:

Sleep Apnea

Date of First Diagnosis:

Month

Day

Year

Has the Sleep Apnea been diagnosed as:

Obstructive

Central

Mixed

Unknown

Has the severity of the Sleep Apnea been:

Stable

Increasing

Decreasing

Fluctuating up and down

Unknown

Has an overnight sleep study (Polysomnogram) been done?

Yes

Please provide Date, Sleep Apnea Index, and Oxygen Saturation % of study done:

Click the "+" button to add additional rows.

Date of Study:

Sleep Apnea Index:

Oxygen Saturation%:

How is the Sleep Apnea being treated?

No treatment

Medicated

Weight Loss

CPAP Mask

Surgery (UPPP)

Surgery (Tracheotomy)

Other

Please describe other treatment:

Do you have any of the following?

Overweight

Arrythmia

Coronary Artery Disease

Stroke

Depression

Lung Disease

Do you use any Alcohol?

Yes

Please describe Alcohol usage:

Stroke

Provide Date(s) of Stroke(s) (CVAs) or Mini Strokes (TIAs):

Click the "+" button to add additional rows.

What follow up studies were done following the reported Stroke (CVA) or Mini Stroke (TIA)?

CT Scan

Carotid Ultrasound

MRI Scan

Echocardiogram

Other:

Have you been diagnosed with any following conditions:

Hypertension

Elevated Cholesterol

Peripheral Vascular Disease

Valve Disorders

Cardiomyopathy

Atrial Fibrillation

Most recent blood pressure reading:

Most Recent Cholesterol Reading:

Please provide date of diagnosis and details for each condition selected above:

(e.g. Atrial Fibrillation: Diagnosed 09/2022 – Managed with medication; no recent episodes; regular cardiology follow-ups)

Describe any symptoms experienced at the time of the Stroke (CVA) or Mini Stroke (TIA):

Describe any residual neurologic deficits or other residual effects from the Stroke (CVA):

Substance Use

Have you ever discussed alcohol consumption or concerns about sobriety with a physician?

Yes

Do you currently drink alcohol?

Yes

Please provide Frequency and Type of Alcohol:

Click the "+" button to add additional rows.

Frequency (Daily, Weekly, Monthly)

Type of Alcohol

Have you ever drank substantially more than now?

Yes

Please provide Frequency, Type of Alcohol and Duration:

Click the "+" button to add additional rows.

Frequency (Daily, Weekly, Monthly)

Type of Alcohol

Dates: From - To

Have you ever been arrested for driving under the influence (DUI) or for driving while intoxicated (DWI) ?

Yes

Please provide details and dates:

Have you ever experienced any of the following?

Blackouts

Convulsions

Delirium Tremens

Protein or Blood in Urine

High Blood Pressue

Psychological Disorders

Hepatitis A, B, or C

Liver Problems

Depression

Emotional Disorder

Kidney Disease

Other Medical Condition

Please describe "Other Medical Condition":

Do you currently attend, or have you previously attended, AA meetings?

Yes, I currently attend

Yes, I have attended in the past

No, I have never attended

How often do you attend?

Please indicate when and why you stopped attending AA meetings:

Have you ever used any controlled substances (excluding marijuana)?

Yes

Please provide the Type of Drug, Details, Frequency and Date of Last Use

Click the "+" button to add additional rows.

Type of Drug

Details

Frequency of Use

Date of Last Use (if applicable)

Have you ever been tested for the use of controlled substances?

Yes

If yes, please provide date and details:

Have you ever been convicted of drug-related offenses?

Yes

If yes, please provide date and details:

Have you ever informed a physician of your use of controlled substances (excluding marijuana)?

Yes

If yes, please provide details:

Have you ever been admitted to a hospital or treatment facility for substance use or related treatment?

Yes

If yes, please provide date and details:

Please provide any additional information that would help us negotiate the lowest rates possible:

Other Medical Condition(s)

Please provide details of all other medical condition(s):

Good Health Credits:

Our carriers with crediting programs worked diligently to create their own internal list of “credits,” and as long as your clients demonstrate they are leading a healthy lifestyle, carriers apply credits to improve their overall rating. Please see the list below and advise which credits apply, and we will pass the information along on your behalf!

Do You Have Regular Preventive Medical Care And Follow Ups?

(Age Appropriate Screenings, Preventive Cancer Screening Tests, Preventive Heart Screening Tests, Etc)?

Yes

Do you exercise on a Regular Basis?

Yes

Do you maintain a Healthy Diet?

Yes

Is Your Income Greater Than $100,000 Or Net-worth Greater Than $1,000,000?

Yes

Do you have a College Degree?

Yes

Any Driving/Moving Violations in the Last 5 Years?

Yes

Overflow of Information

Please provide any information you would like to share that has not been mentioned elsewhere in this form.

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Informal Review Submission

HIPAA Authorization

Advisor Information

Client Information

Insurance Plan Information

General Health Information

Arthritis

Asthma

Cancer

Cardiac

Diabetes

Hepatitis

Multiple Sclerosis (MS)

Pancreatitis

Polycystic Kidney Disease

Sarcoidosis

Sleep Apnea

Stroke

Substance Use

Other Medical Condition(s)

Good Health Credits:

Overflow of Information

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