RAM Group

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Questionnaires & Prelim Forms

Table of Contents

Preliminary Application Forms

Questionnaires

Request–A-Quote

Preliminary Application Forms

Prelim Apps: Use these forms when trying to obtain the best possible tentative underwriting offer from multiple carriers on impaired risk cases of over $5,000 in target premium or on any case over $50,000 in target premium. Please note tentative offers are NOT contractual offers of coverage, and all tentative offers are subject to completion of approved carrier application forms and formal underwriting by the respective carrier.

• Informal Application Life, DI & LTC
• PRIVACY POLICY
• HIV Consent Form
• HIPAA Authorization

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Questionnaires

Questionnaires: Use when client has specific medical ailments (i.e. Diabetes, heart trouble etc..), alcohol abuse history, hazardous avocations, foreign travel, or for personal or business financial info.

Medical Impairment Questionnaires

• Anemia
• Anxiety Disorder-Stress
• Arthritis
• Back Disorder
• Bladder Cancer
• Build & Blood Pressure
• Cancer (all types)
• Cerebral Vascular-Neurological
• Chest Pain
• Coronary-Heart
• Depression
• Diabetes
• Eating Disorders
• Elevated PSA
• Fybromyalgia
• GastroIntestinal-Colitis-Crohn’s Disease
• Headaches-Migraines-Concussion
• Hepatitis
• Immunodeficiency-AIDS
• Kidney-Urinary
• Leukemia
• Liver
• Lupus & Connective Tissue
• Multiple Sclerosis (MS)
• Peptic Ulcer
• Prostate Cancer
• PVD & Neuropathy
• Respiratory Disease & Asthma
• Seizure or Fainting
• Skin Cancer & Melanoma
• Tuberculosis
• Valvular Heart Surgery

Drug/Alcohol Questionnaires

• Alcohol Use
• Drug Usage
• Driving Violation Questionnaire

Tobacco Questionnaires

• Tobacco Use
• Former Tobacco User Declaration

Hazardous Avocation/Occupation Questionnaires

• Aviation
• Avocation Hazardous Sports-SCUBA-Skydiving
• Avocation Motor Sports Racing
• Crop Dusting (Aviation)
• Driving Violation Questionnaire
• Occupation

Financial Questionnaires & Forms

• Business Financial Statement
• Personal Confidential Financial Statement
• W-9 Form (IRS)
• W-8 BEN Form (IRS)
• IRS 5305-SEP Form

Foreign National/Travel Questionnaires & Forms

• Foreign National Questionnaire
• Foreign Travel Questionnaire
• W-8 BEN Form (IRS)

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Request-A-Quote

Request-A-Quote: Use when you would like a quote on any Life, LTC, DI, or Annuity business, use the “Fax the Facts” cover sheet only on Life, LTC & DI. Please note quotes are NOT contractual offers of coverage, and all quotes are subject to completion of approved carrier application forms and formal underwriting by the respective carrier.

• Fax The Facts Cover Sheet
• Annuity General Purpose Request
• Disability Income General Purpose Request & Questionnaire
• Life Insurance General Purpose Request & Questionnaire
• Long Term Care Request & Questionnaire
• Advanced Estate/Financial Planning Fact Finder
• Pension, 412i, 419A, or Profit Sharing Quote Request
• Group Ancillary Product Quote Census (i.e. Group Life, DI, LTC, Voluntary etc..)
• Group Health Quote Census

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For Agent/Broker Use Only

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