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Depression Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1. CLIENT HAS BEEN DIAGNOSED AS:
HAVING DEPRESSION
BEING MANIC DEPRESSIVE (BIPOLAR)

2. HAS THE CLIENT EVER ATTEMPTED SUICIDE? THAN BY ACCIDENT?
IF YES,
Month
  Year
Month
  Year

3. HAS THE CLIENT EVER BEEN HOSPITALIZED FOR DEPRESSION?
IF YES,
Month
  Year
Month
  Year

4. DURING THE PAST 12 MONTHS, HAS THE CLIENT MISSED WORK DUE TO DEPRESSION?
IF YES, PLEASE DETAIL AND LIST NUMBER OF OCCASIONS AND AMOUNT OF TIME MISSED:

5. IS THE CLIENT CURRENTLY TAKING MEDICATION FOR DEPRESSION?

6. IS THE CLIENT CURRENTLY SEEING OR HAS SEEN A MENTAL HEALTH THERAPIST?
Not Currently
No
Yes. IF YES, OR NOT CURRENTLY, PLEASE DETAIL HOW OFTEN, FOR HOW LONG, AND THE DATE OF THE LAST VISIT:

7. CLIENTS MARITAL STATUS:

8. IS THE CLIENT CURRENTLY RECEIVING. OR IN THE PAST RECEIVED, DISABILITY BENEFITS DUE TO DEPRESSION OR OTHER DEPRESSION?
IF YES, PLEASE DETAIL START AND END DATES:
START: Month
  Year
END: Month
  Year
IS STILL GETTING BENEFITS

9. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

10. CLIENT'S OCCUPATION

11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL

12. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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