Depression Quote Request

Client Information

Name

*

Address

City, State, Zip

*

Day Phone

*

Evening Phone

Cell Phone

Fax

Email

*

Date of birth

mm dd yy *

Sex

M F *

Height

*

Weight (lbs.)

*

Smoker

Yes No *

(if yes, also complete tobacco questionnaire)

Insurance amount

Insurance type

Additional
insured's name
(only if applying
for Survivor UL)

Other company(s) actions

Date applied

mm yy

Company

Declined

Postponed

Rated table

1. Have you been diagnosed as?
		Depressed Manic Depressive (bipolar)
2. Has suicide ever been attempted?
		Yes No
	if yes	mm yy
	details
3. Have you ever been hospitalized for depression?
		Yes No
	if yes	mm yy
4. Have you ever lost work, in the last 12 months, for depression?
		Yes No
5. Is medication currently being taken for depression?
		Yes No
	if yes, list
6. Are you currently seeing a mental health therapist?
		Yes No
	if yes, list frequency
7. When was the last visit to a mental health therapist?
		mm yy
8. Are there any other illnesses/impairments?

9. What medications are currently being taken?

10. Has either parent, or any sibling, died before age 65, other than by accident?
	Yes No (If yes, list relationship(s) and cause)
	cause
	cause
	cause
Additional Information

* Required