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Sleep Apnea
Thank you for taking the time to share the details of any health issues. This information is private and will not be shared with any insurance companies. The sole purpose of providing this information is so I can review this with my underwriting advisor and determine which life insurance company will provide the best offer of coverage for your particular circumstances.
Please know that I am on your team and my goal is to help you get approved for your insurance at the lowest possible cost. The more I know before underwriting begins; the better I can help negotiate the lowest rate for your coverage. Please don’t hesitate to contact me with any questions.
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* Indicates required question
Proposed Insured Name
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Your answer
Sex
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Choose
Male
Female
Date of Birth
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MM
/
DD
/
YYYY
State of Residence
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Your answer
Amount of coverage
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Your answer
Maximum Premium/year
Your answer
Type
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Term
Permanent
If term – length of term?
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10 – 30 years
Your answer
Height
*
Your answer
Weight
*
Your answer
Do you currently smoke cigarettes?
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Yes
No
If no, did you ever smoke?
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Never / Quit (When?)
Your answer
Do you currently use any other tobacco products (e.g. cigars, pipe, snuff, nicotine patch, Nicorette gum, etc)
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Yes
No
If Yes, please provide details (include date last used)
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Your answer
Please provide date of diagnosis
MM
/
DD
/
YYYY
Has the Sleep Apnea been diagnosed as:
Mild
Moderate
Severe
Obstructive
Central
Mixed
Unknown
Clear selection
Has the severity of the Sleep Apnea been:
Stable
Increasing
Decreasing
Fluctuating up and down
Unknown
Clear selection
If an overnight sleep study (Polysomnogram) has been done, specify 1) Date, 2) Apnea Index, 3) Apnea/Hypopnea Index, and 4) Oxygen saturation
Your answer
Date Treatment began
MM
/
DD
/
YYYY
How is the Sleep Apnea being treated?
No treatment
Medicated
Weight Loss
CPAP Mask
Surgery (UPPP)
Surgery (tracheotomy)
Other:
Clear selection
Does the proposed insured have any of the following?
If yes, provide details in the question below
Overweight
Arrhythmia
Coronary Artery Disease
Stroke
Depression
Lung Disease
Other:
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Are there any other health conditions or lifestyle issues that may impact life underwriting? If yes, please describe
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Your answer
Does the proposed insured take any current medications?
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Yes
No
If Yes, provide details
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For every Medication specify Condition Treated, Dates Used, Quantity Taken, and Frequency Taken
Your answer
E-mail
*
Your answer
Phone
*
Your answer
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