Second Underwriting Opinion

Use this form if you have assisted a client who was rated or declined within the past 12 months. Submit with prior:

Application
Paramedical Exam
Lab Results (not just the ticket)
EKG
Underwriting, aviation, avocation and similar questionnaires
Underwriting comments explaining rating or decline
Signed HIPAA (e-signature is OK)

Depending on the complexity of the case, please allow 24-48 business hours for initial response. We’ll be in touch ASAP. Prefer to discuss a case in advance? Call a member of the Marketing Team to strategize.

Financial Advisor Name

First Last

Phone

Email address(es) for others who should be cc'ed with our reply:

APPLICANT INFORMATION

Name

First Last

Date of Birth

Gender

Male

Female

State of Residence

PRIOR APPLICATION

Prior Application(s) - Please tell us about all applications and agencies that have reviewed the case in the past 12 months:

Which medical conditions, exam, or lab findings caused the rating or decline? If multiple conditions (e.g. diabetes, heart disease, tobacco use) list all:

Which carrier(s) have reviewd the app?

What were the ratings / declines?

When will they reconsider?

Please cut and paste specific comments from the underwriter explaining their reasons for the rating or decline. The more detail, the better.

Coverage: Term | UL | SUL | Other:

Coverage for how many years?

Max annual premium?

Specify riders or features to include:

Please upload prior apps, paramedical exams, lab results (not just the lab ticket), EKG, underwriting / aviation / avocation questionnaires, and anything else helpful you may have, along with our signed HIPAA.

Drop files here or

Max. file size: 50 MB.

APPLICANT INFORMATION

PRIOR APPLICATION

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