Impaired Risk Tobacco Questionnaire
Agent Information
Agent Name
Address
Phone
Fax
E-Mail
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
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
Additional Information