AFP: Impaired risk life insurance

Impaired Risk

Approximately 50% of life insurance applicants are incorrectly rated or declined due to outdated underwriting manuals. Let AFP Insurance evaluate you as an individual, not as part of a larger group called Table 6, Table 8, etc.

Our firm focuses on four key factors:

Control - Is the health impairment controllable?
Compliance - Are you following doctors' orders and making lifestyle adjustments?
Family History - Do you have a favorable health history?
Complete Medical Information - Do we have all pertinent.

Underwriting Questionnaire

Personal Information

First Name:

Last Name :

State :

Daytime Phone:

Date of Birth :

mm dd yy

Evening Phone:

Gender :

Male Female

Cell Phone:

Height:

Best Time to Call:

Weight (lb):

Email:

Coverage Information

Tobacco:

Yes No

Type of Tobacco:

How much?

Amount of Insurance:

Type of Insurance:

Have you previously been declined for insurance? Yes No

Which Company?

Health Information

Do you have high blood pressure? Yes No

Systolic Rating:

Diastolic Rating:

Do you have high cholesterol? Yes No

Cholesterol:

HDL Ratio:

Family history (Parents, Siblings) of cancer or heart disease? Yes No

Parent

Age of Diagnosis:

Age of Death:

Siblings

Age of Diagnosis:

Age of Death:

Health Conditions

Cancer	Alcoholism	Alzheimer's
Depression	Heart Disease	Sleep Apnea
Diabetes	Hepatitis	Liver Disease
Rheumatoid Arthritis	Stroke	Parkinson's
Kidney Disease	Leukemia
Other Details:

Hazardous Activities

Activities	Details:
Aviation
Scuba Diving
Other
Moving Violations, DUI:	Yes No	Details:

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