BRENDANWOOD FINANCIAL BROKERAGE

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CONTACT

PHONE: 317.731.6509

FAX: (317) 731-6738

ADDRESS

11711 N. MERIDIAN STREET 
SUITE 225 
CARMEL, INDIANA, 46032

USA

HOURS: 9-5, M-F EST

©2019 BY BRENDANWOOD FINANCIAL BROKERAGE, LLC.

Below Standard Life Quote

Agent Information​

Client Information​

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Plan Design​

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Rider Selection​

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Medical Questions​

1. Has the applicant been previously declined for life insurance?

If yes, please explain:

3. Is the applicant currently employed?

If no, please explain:

5. Within the last five years, has the applicant had a moving violation, reckless driving, or DUI/DWI?

If yes, please explain:

2. Is the applicant currently disabled?

If yes, please explain:

4. Does proposed insured have any family history (parent, sibling) of death before age 70 due to cardiovascular, cerebral vascular disease, diabetes, or cancer?

If yes, please explain:

6. Does the applicant have any prior felony convictions?

If yes, please explain:

Does the applicant participate in any of the dangerous activities below?

Does the applicant intend to travel to any foreign country (excluding Canada)?

If yes, please explain:

Medical Conditions​​

Has the applicant even been diagnosed by a licensed physician as having any of the following conditions?

If you checked any of the listed conditions, please provide full details below.

Perscriptions​

Currently Taking?

Currently Taking?

Currently Taking?

Currently Taking?

Health Concerns For Conditions​​

Please Address Any Applicable Questions

Asthma
1. The frequency of attacks or hospitalizations?
2. Any oral steroids including inhalers that are steroidal?
3. Smoker?
4. Stable pulmonary function tests?
5. Any diagnosis of COPD or emphysema?
6. How long diagnosed?

 

Cancer
1. Where cancer originated?
2. What stage of cancer, 1-4? 4 being metastasis and uninsurable.
3. What kind of treatment and last date of treatment, if fully recovered (including surgery, radiation or chemotherapy?
4. When diagnosed?
5. PSA for prostate cancer <1?
6. If melanoma need Clark level and depth of invasion?


COPD/Emphysema
1. What medications, inhalers, and nebulizer?
2. Does the client smoke?
3. Need to know if the client has stable pulmonary function tests?
4. Any hospitalizations?
5. Any limitations or shortness of breath?
6. Any oxygen use, daily steroid use or hospitalizations?
7. When diagnosed?


Crohn’s disease
1. When diagnosed?
2. What treatment or meds is the client using?
3. How frequent are flare-ups or hospitalizations?
4. Weight stable?


Diabetes
1. What type, 1 or 2?
2. When diagnosed?
3. How well controlled, last hemoglobin A1C?
4. Any diabetic complications (neuropathy) (nerve damage), retinopathy (eye), nephropathy (kidney damage), or circulatory problems?
5. Weight and height stable and within the guidelines?
6. What medications, oral or insulin?
7. Any heart conditions?


Heart disease
1. Any heart surgeries, when and what type, bypass (# of bypasses), angioplasty, pacemaker, or heart valve replacement?
2. Recovered?
3. What are medications taking?
4. Any congestive heart failure/atrial fibrillation/heart attack/chest pains.
5. Is the client having regular follow-ups and/or testing (last seen and test results)

 

Lupus
1. What type? Discoid or systemic?
2. When diagnosed?
3. If systemic, what organs affected and how severe are they affected?
4. What treatment or meds is the client using?
5. How many flare-ups or hospitalizations?


Stroke/CVA/TIA
1. How many strokes?
2. When was the episode?
3. Any residuals, such as numbness, weakness, pain, slurred speech, or visual impairment?
4. Any limitations that require a cane or assistance?
5. Any findings on a CT of white matter changes, small vessel disease, ischemic changes, microvascular changes and lacunar infarcts?
6. Any cognitive abnormalities?


Sleep Apnea
1. When diagnosed?
2. The severity of the condition?
3. Does the client use a CPAP machine? Is the machine hooked to oxygen? If it is then companies will decline.
4. Any other treatment?
5. Stable pulmonary function tests?