Completion of a faCt finder will accelerate the underwriting process
Name:_________________________________________________ Date of Birth/Age: __________________________ Address: _____________________________________________ Social Security Number:_________________________ _________________________ Email: ____________________________ Phone #:__________________________
e4 Brokerage, LLC, 2280 45th St. South, Suite C, Fargo, ND 58104 l Phone: 701-356-1270 l Fax: 701-356-6581 Page 1 of 2
Plan of insurance requested:
State of Residence: _______ Face Amount: __________________ Desired Premium Range: ___________________ Individual: Term______ UL IUL VUL WL Survivorship: SUL SVUL SWL SIUL
Present nicotine Use:
None Cigarettes - frequency of use per day: ________
Cigars Pipe Dip Chew Nicotine Gum Other: ___________________________ Quantity Per Month: _________________________
former nicotine Use:
List Each Type of Nicotine Used: ________________________________________________________________________ Quantity: _________________________ Frequency: _______________________ Date of Last Usage: ___________
Build:
Height: ________feet ________inches Weight: _____________pounds family History (family history is a consideration for each rate class):
To your knowledge, is there any family history (parent or siblings), prior to age 60, of cardiovascular disease, cerebrovascular disease, heart disease, stroke, diabetes, or cancer? Yes No
If yes, provide full details:
Father: Impairment _________________________ Age at Onset ______ Age at Death (if deceased) ______ Mother: Impairment _________________________ Age at Onset ______ Age at Death (if deceased) ______ Siblings: Impairment _________________________ Age at Onset ______ Age at Death (if deceased) ______
Blood Pressure and Cholesterol:
Most recent BP reading: ______/______
Most recent total cholesterol: _________mg Most recent cholesterol/HDL ratio:_________
Are you currently taking medication for blood pressure? No Yes, name/dosage of meds:_____________ Are you currently taking medication to lower cholesterol? No Yes, name/dosage of meds:____________
aviation/avocation:
In the past 5 years have you or do you intend to participate in any of the activities listed? None Flying Racing Sky Diving Scuba Diving Any Dangerous Activities
Details: _______________________________________________________________________________________________
All personal information protected by HIPPA regulations (see HIPPA form attached with supplemental forms)
QUiCK faCt-finder tOOLS
Any future plans to live or travel outside the USA? No Yes
If yes, please provide: Purpose _________________________________________________________________________ Cities ___________________________________________________ Countries ____________________________________ Frequency ______________________________________________ Duration ____________________________________
travel:
driving History:
Have you had any of the following motor-vehicle-related incidents in the past 10 years?
Moving violation Reckless driving DWI or DUI License suspension License revoked Dates: ______________________________________________
Details: _______________________________________________________________________________________________ Medical History:
Have you ever had, been told you had, or been treated for any of the conditions listed? If yes, check all that apply:
List dates, diagnosis, details, treatment, plus names, addresses, and phone numbers of all physicians consulted in the last 5 years:
______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Alcohol abuse Alzheimer’s/dementia/cognitive impairment Asthma Cancer Cirrhosis COPD
Coronary artery or cerebrovascular disease Crohn’s disease
Depression/anxiety Diabetes
Drug abuse Epilepsy
Heart murmur/valve disease Hepatitis
Irregular heartbeat/palpitations Kidney disease
Lupus
Multiple sclerosis
Peripheral vascular disease Rheumatoid arthritis
Sleep apnea Stroke
Other ___________________________________
e4 Brokerage, LLC, 2280 45th St. South, Suite C, Fargo, ND 58104 l Phone: 701-356-1270 l Fax: 701-356-6581 Page 2 of 2
All personal information protected by HIPPA regulations (see HIPPA form attached with supplemental forms)
QUiCK faCt-finder tOOLS
Underwriting AUthorizAtion reqUirements
Attached is the e4 Brokerage, LLC, underwriting authorization.
Having your client sign this form gives both you and your client the ability to obtain the best offer possible for their individual situation. This authorization gives e4 Brokerage, LLC, the opportunity to present the medical information of a particular case to several different carriers to see how they view the case.
When submitting the underwriting authorization to e4 Brokerage, LLC, without a formal application, please complete as many questions as possible on the attached Insured Information form:
• Client’s full name • Client’s date of birth
• Client’s social security number • Client’s address
• Name, address, and phone number of physician or facility where medical records can be obtained. If medical records are ordered directly from the physician or facility by e4 Brokerage, LLC, the agent is responsible for the cost of the records if the case is not placed with a carrier
When submitting the underwriting authorization to e4 Brokerage, LLC, with a formal application, please be sure to include the following details:
• Contracting for which the company the application is being written, including resident licensing. Also include nonresident licensing and proof of Errors and Omissions if required, AML certificate
• All completed, signed, and dated state required new business forms
We appreciate your business. If you have any questions, please contact us at 701-356-1270.
hiPAA ComPliAnt - Underwriting AUthorizAtion
e4 Brokerage, LLC, 2280 45th St. South, Suite C, Fargo, ND 58104 l Phone: 701-356-1270 l Fax: 701-356-6581 e4agentHIPPA.0214
For the purpose of obtaining the insurance coverage that I have requested, I hereby authorize e4 Brokerage, LLC (the “Representative”) and its affiliated agencies, to disclose my personal financial and health information to the insurance companies listed at the bottom of this page and to insurance agents and brokers acting on my behalf with respect to obtaining such insurance coverage.
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, Pharmacy Benefit Manager or other health care provider that has provided treatment or services to me or on my behalf within the past 10 years (“my Providers”) to disclose my entire medical record and any other information that may be considered protected health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) concerning me to the Representative and its staff, affiliated companies and/or entities, insurance companies and their re-insurers. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.
By my signature below, I acknowledge that any agreements I have made with my Providers that restrict disclosure of my medical records and any associated HIPAA protected health information do not apply for purposes of this authorization and I instruct my Providers to release and disclose my entire medical record without restriction to the Representative. I understand that any information that is disclosed pursuant to this authorization may be subject to re-disclosure and no longer covered by certain federal rules governing privacy and confidentiality of health information.
The information contained in these medical and financial records will be held in confidence and may be used only for the purpose of the procurement, or the evaluation or underwriting for the possible procurement, of life, health, long term care, or other insurance products. The contents therein may be reviewed and assessed by a qualified staff consisting of medical directors, underwriters, underwriting assistants, or other related employees involved in the submission, receipt or evaluation of insurance applications or prospective applications of the insurance companies listed at the bottom of this page and their re-insurers as well as the Representative and its staff, employees and affiliated companies.
This authorization shall be valid for twenty-four (24) months from the date below. A copy of this authorization shall be as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that I may write to the Representative to revoke this authorization and that the revocation will take effect when the Representative receives my written request. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I also understand that, to the extent that other law allows an insurance company listed below to contest a claim under an insurance policy or the insurance policy itself, my revocation of this authorization may not be effective.
I understand that if I refuse to sign this authorization, the Representative may not be able to provide full and complete information about the insurance coverage and its cost that may be available to me. I also understand and acknowledge that each of the insurers listed on this form, or to which I may formally apply, may require me to sign a similar authorization used exclusively by such insurer before they will process my application or offer insurance coverage. I understand that my refusal to sign this authorization will not affect my ability to obtain treatment or payment for services, or my eligibility for health care benefits; provided, however, that if a health care service (e.g, a physical exam) is requested solely for the purpose of creating protected health information to be disclosed to a third party, the health care provider may refuse to provide the service if I do not sign this authorization.
AUthorizAtion for releAse of heAlth informAtion
e4 Brokerage, LLC, 2280 45th St. South, Suite C, Fargo, ND 58104 l Phone: 701-356-1270 l Fax: 701-356-6581
The insurance carriers represented below uphold the highest degree of security and confidentiality. The applicant has reveiwed the companies below and understands that any of all of the institutions listed may be used to secure the best insurance or financial offer.
AUthorizAtion for releAse of heAlth informAtion
• Accordia • AIG Life • Allianz • American General • American National • Assurity • AVIVA • AXA • Banner Life • Cincinnati Life • Columbus Life • Fidelity & Guaranty • Fidelity Life
• Foresters Life • Genworth • Great West Life
• National Western • New York Life • North American • Ohio National • Pacific Life • Penn Mutual • Principal Life • Protective Life • Prudential • Sagicor • SBLI • Symetra • The Standard • Transamerica • United of Omaha • Voya • ________________ • Guardian Life • ING • Illinois Mutual • John Hancock • Lafayette Life • Legal & General • Life of the Southwest • Lincoln National • Mass Mutual • Met Life • Midland Life • Minnesota Life • Mutual of Omaha • Mutual Trust Life
• National Life of Vermont • Nationwide
________________________________________________ Proposed Insured’s Signature
________________________________________________ Print Agent/Witness Signature
_______________________________________________ Proposed Insured’s Name
_______________________________________________ Agent/Witness Name
___________________________________ ___________________________ _________________________ Proposed Insured’s Social Security # Proposed Insured’s Date of Birth Signed and Dated On ______________________________________________________________________________________________________
At (City, State, Zip Code)
I have read and completely understand this document. I have the right to rescind my authorization. I have received a copy of this document. I agree this document shall be valid for a period of twenty-four (24) month from the date below.
signAtUre AUthorizAtion
e4 Brokerage, LLC, 2280 45th St. South, Suite C, Fargo, ND 58104 l Phone: 701-356-1270 l Fax: 701-356-6581
