In order for Banner to contact your client to begin the application process, please obtain the answers to the following questions. Once you have the completed worksheet you may enter the case by going to www.merzagency.com, clicking on Quick Apps from the top toolbar, then choose Bellevue & following the prompts. Any questions? Call Kristi at 425-453-1264
REQUIRED QUESTIONS
1. Full Legal Name
2. Birthdate
3. Gender
4. Social Security #
5. Home Address including zip code
6. Have you ever used any form of tobacco or nicotine based products? Y or N
a. If Yes, What form of tobacco or nicotine based products & when did you last use? Month & Year?
7. Do you or have you ever consumed any type of alcoholic beverage? Y or N
a. If Yes, Do you have a history of alcohol abuse? Y or N
b. If Yes, Has there been any abuse in the last 10 years? Y or N
8. Have you had any DUI’s in the past 5 years? Y or N
a. If Yes, Have you had any DUI’s in the past 3 years? Y or N
9. Do you have or have you ever used any type of illegal drugs? Y or N
a. If Yes, Do you have a history of substance abuse? Y or N
b. If Yes, Has there been any abuse in the last 10 years? Y or N
10. Have you had more than two moving violations in the past three years? Y or N
11. What is your height & weight?
12. Has any parent or sibling had a history of cardiovascular disease before age 60? Y or N
a. If Yes, Has either parent died as a result of cardiovascular disease before age 60? Y or N
b. If Yes, Have both parents died as a result of cardiovascular disease before age 60? Y or N
13. Amount & Duration (10, 15, 20 or 30) of Term Insurance?
14. Billing Frequency: Annual, Semi-Annual, Quarterly or Monthly Bank Draft
15. Is this prospective policy to replace any existing insurance? Y or N
16. What is the purpose of this insurance? Family Protection, Buy/Sell, Keyman, Income Replacement or Other
17. If the Owner of this policy is not the Proposed Insured, please provide the Owner Name, City, State & Zip
18. Date & Time for Banner to contact you for telephone interview? (available M-F from 6 am – 7:30 pm) *Most interviews take approximately 30-40 minutes*
19. Primary Phone Number
20. Secondary Phone Number
21. Email Address
22. Primary Beneficiary: Full Name & Relationship to Insured
To uncover other potential underwriting issues it’s recommended that you ask the following information (this is NOT required but will help you deliver a more accurate quote):
OPTIONAL QUESTIONS
- Are you a U.S. Citizen (coverage may NOT be available if you aren’t a U.S. Citizen or Permanent Green Card Holder).
- Do you participate in any hazardous hobbies or sports (i.e. mountain climbing, hang gliding, ballooning, auto racing, parachuting, scuba diving or flying)? If Yes, an extra premium may be required depending on risk.
- In the next 2 years, do you intend to travel or reside outside the U.S. for more than 4 consecutive weeks other than for a vacation?
- Do you have any personal history of cancer, heart disease, diabetes or stroke? If Yes, coverage may still be available but at an increased price.
- Have you consulted a doctor or clinic in the past 5 years? If Yes, please provide date & details.
- Have you been hospitalized for any reason within the past 10 years? If Yes, provide dates/details.
- Has your weight changed by 10 or more lbs. in the past year? If Yes, provide number of lbs. lost & reason.
- Do you currently take or have you taken any medication in the past 5 years? If Yes, provide names of medications/dosages/reasons for taking.
Banner Client Worksheet / Version 9.29.14
The Merz Agency, Inc. ©