Informal Inquiry - Berson

Informal Inquiry
Please fax, mail or email this form to Berson-Sokol
23500 Mercantile Road Suite C
Cleveland, OH 44122
P: (216) 464-1542
T: (800) 543-6000
F: (216) 464-6522
www.berson-sokol.com
This informal inquiry is used to gather specific information that may impact underwriting and rating classification. This is not an application for
insurance and in no way guarantees a specific underwriting class or binds any insurance coverage with any carrier.
Personal History — this section must be completed
Name: ___________________________________________________  Male
 Female Social Security # _________________________
Address: ________________________________________________ City: __________________________ State: ______ Zip: ____________
Date of Birth: ______________________ Height: _____________ Weight: _____________ Occupation: _____________________________
Are you a US Citizen?
 Yes  No
Any tobacco or nicotine use (including cigarettes, cigars, pipe, nicotine gum or patch)?
Type: ___________________________________ Date of last use: __________________
Agent Information — this section must be completed
Name: ___________________________________________________ Phone Number: ______________________________________________
Address: _________________________________________________ City: ___________________________ State: _____ Zip: ___________
Fax Number: ____________________________________________ Email: ________________________________________________________
Requested Plan of Insurance — this section must be completed
Type of Insurance: _______________________________________________________________________________________________________
Face Amount: ________________________ Premium Amount Desired: _______________________________  Annually
 Monthly
If you are replacing coverage, will there be any 1035 exchange money with the replacement?
 Yes  No If yes, what amount will be carried over? __________________________
Please list all inforce and pending coverage:
Company
Policy/Application Date
Amount
Rating Issued
Current Premium
To Be Replaced?
Y / N
Y / N
Y / N
Medical History — this section must be completed
1. Please list you primary care physician’s name, address and phone number.
Date
Illness
Date
Illness
When did you last consult him/her? Why?
2. Please list any other physicians consulted in the last five years and the reason why.
Page 1 of 3
Rev. 09/2012
23500 Mercantile Road Suite C
Informal Inquiry
Cleveland, OH 44122
P: (216) 464-1542
T: (800) 543-6000
F: (216) 464-6522
Name: _____________________________________________________
www.berson-sokol.com
Medical History Continued — this section must be completed
3. What hospitals, clinics or other health facilities have you ever been treated?
Date
Illness
4. Please list all current medications and dosages.
Date
Illness
Family History — this section must be completed
Have any immediate family members (parents, siblings) been diagnosed or died from heart disease, cancer or diabetes?
 Yes
 No
If yes, please provide details:
Relationship
Drug and Alcohol Usage Questionnaire
1. Do you currently drink alcohol?
Age at
Onset
Diagnosis
 Yes
Age at Death
(if deceased)
check here if this section is not applicable
 No
2. Did you ever drink substantially more than present?
 Yes
 No
Date of last consumption: ___________________________________
If yes, when? _______________________________________________
Type:
Type:
Amount per week:
Beer
Beer
Wine
Wine
Liquor
Liquor
Amount per week:
3. Have you ever consulted a doctor or received treatment because of alcohol use?
4. Have you ever been arrested for driving under the influence of alcohol?
5a. Have you ever used illegal drugs or sought treatment because of drug use?
 Yes
 Yes
 Yes
 No
 No
If yes, date: _________________________
 No
If yes, provide details:
5b. Types of drugs used: __________________________________________________________________________________________________
5c. Date of last use: ______________________________________________________________________________________________________
5d. Doctor/Facility name and address: _______________________________________________________________________________________
Page 2 of 3
Rev. 09/2012
23500 Mercantile Road Suite C
Informal Inquiry
Cleveland, OH 44122
P: (216) 464-1542
T: (800) 543-6000
F: (216) 464-6522
Name: _____________________________________________________
Cardiac History
www.berson-sokol.com
check here if this section is not applicable
1. Date of diagnosis: ______________________
2. Number of diseased vessels: ____________________________________________________________________________________________
3. Dates, types and results of tests (ekgs, echocardiograms, catheterizations): ______________________________________________________
______________________________________________________________________________________________________________________
4. Dates and details of treatment/surgery (angioplasty, bypass): _________________________________________________________________
______________________________________________________________________________________________________________________
5. Date and results of last stress EKG? _______________________________________________________________________________________
6. Cardiologist/Facility address and phone number: ____________________________________________________________________________
______________________________________________________________________________________________________________________
Cancer History
check here if this section is not applicable
1. Date of diagnosis: ______________________
2. Exact name and location of cancer: _______________________________________________________________________________________
______________________________________________________________________________________________________________________
3. Stage and grade: ______________________________________________________________________________________________________
4. Dates and details of treatment/surgery: ___________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
5. Oncologist/Facility address and phone number: _____________________________________________________________________________
______________________________________________________________________________________________________________________
Diabetes History
check here if this section is not applicable
1. Date of diagnosis: _________________________
2. Treatment (list medications and dosages): _________________________________________________________________________________
______________________________________________________________________________________________________________________
3. Do you regularly test your blood glucose?
 Yes
Frequency: ____________________________________
 No
Last result: __________________________________
4. Last glycohemoglobin (A1C) test result: ___________ mg%
Date: ________________________________
5. Have you ever been diagnosed with having protein and/or microalbumin in your urine?
 Yes
 No
6. Have you EVER had:
Page 3 of 3
a. eye problems?
 Yes
 No
d. kidney problems?
 Yes
 No
b. heart problems?
 Yes
 No
e. neuritis/neuropathy?
 Yes
 No
c. high blood pressure?
 Yes
 No
f. insulin reactions?
 Yes
 No
Rev. 09/2012
AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
TO GENERAL AGENT OR BROKER
I,____________________________________________________________________________________
Print Name of Proposed Insured
_____________________________________________________________________________
Address (Street, City, State, Zip Code)
hereby authorize the insurance companies listed below, their employees, underwriters, officers or affiliates, to disclose any and all
medical information to the Broker General Agent, The Berson-Sokol Agency, which information has been collected in connection to
my application for insurance dated _____________, and submitted through the Berson-Sokol Agency. Information includes, but is
not limited to the results of any physical examinations or tests, electrocardiogram, chest x-ray, and Attending Physician
Statements.
The purpose of this authorization is to facilitate submission of this information to the Broker General Agent to other insurers to
evaluate an application on my life. The companies listed below assume no liability with respect to any application for life or longterm care insurance to other companies, and makes no representation as to the completeness or accuracy of the information. I
also understand it is my responsibility to disclose any and all requested medical information to any insurance carrier to which I
apply for insurance coverage.
I further understand that the privacy policies of those companies listed below does not extend to the copy of the information
provided to The Berson-Sokol Agency, (the Broker General Agent) and/or the Broker.
This authorization is effective as of the date it is signed, and shall continue for six (6) months unless otherwise provided by law. I
understand I may revoke this authorization by providing written notification to the insurance company holding my life insurance
application, which revocation shall be subject to the rights of the insurance company to the extent the insurance company has
acted in reliance on the notification prior to notice of revocation.
A copy of this authorization shall be as valid as the original.
I acknowledge that I have received a copy of this authorization from The Berson-Sokol Agency and/or its representatives.
________________________________________________
Signature of Proposed Insured
_________________
Date
Insurance companies covered by this agreement:
American General
American Memorial
American National
Assurity
Aviva
Banner Life
CSAC/Farm Bureau
Fidelity Life
Genworth Financial
Guardian
BS 05/2012
ING/Reliastar
John Hancock
Lincoln Benefit Life
Lincoln Financial Group
MedAmerica
MetLife
Motorists
North American Co for Life & Health
Presidential
Protective Life
Prudential
SBLI of MA
Transamerica
United Home Life
United of Omaha
United Security Assurance
UNUM Provident
The Marketing Alliance
William Penn