Impaired Risk Depression Questionnaire
Agent Information
*Agent Name (required)
Address
*Phone (required)
Fax
*E-Mail (required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth		mm    dd   yy
Sex		M    F
Height		Feet 2 ' 3 ' 4 ' 5 ' 6 ' 7 ' 8 ' 9 '   Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
Weight (lbs.)
Smoker		Yes    No
		(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type		Select one Term UL Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied		mm   yy
Company
Declined
Postponed
Rated table
1. Has client been diagnosed as?
	Depressed Manic Depressive (bipolar)
2. Has suicide ever been attempted?
	Yes    No
	if yes,   mm   yy
	details
3. Has client ever been hospitalized for depression?
	Yes    No
	if yes,   mm   yy
4. Has client 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. Is the client 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)
	Relationship father mother sister brother    cause
	Relationship father mother sister brother    cause
	Relationship father mother sister brother    cause
Additional Information