Collaborative Planning Group (1)
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AUTHORIZATION FOR RELEASE OF INFORMATION
For the purpose of obtaining the insurance coverage that I have requested, I hereby authorize Collaborative Planning Group and their affiliated agencies, including Brokers Clearing House, LTD., to disclose and share my personal financial (financial plan) and health information to the insurance companies listed at the bottom of this page and to insurance agents and brokers acting on my behalf with respect to obtaining such insurance coverage. I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, Pharmacy Benefit Manager or other health care provider that has provided treatment or services to me or on my behalf within the past 10 years (“my Provides”) to disclose my entire medical record and any other information that may be considered protected health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) concerning me to the Representative and its staff, affiliated companies and/or entities, including but not limited to the insurance companies listed below and their re‐insurers. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychological notes. By my signature below, I acknowledge that any agreements I have made with my Providers that restrict disclosure of my medical records and any associated HIPAA protected health information do not apply for purposes of this authorization and I instruct my Providers to release and disclose my entire medical record without restriction to the Representative. I understand that any information that is disclosed pursuant to this authorization may be subject to re‐disclosure and no longer covered by certain federal rules governing privacy and confidentiality of health information. The information contained in these medical and financial records will be held in confidence and may be used only for purpose of the procurement, or the evaluation or underwriting for the possible procurement, of life, health, long term care, or other insurance products. The contents therein may be reviewed and assessed by a qualified staff consisting of medical directors, underwriters, underwriting assistants, or other related employees involved in the submission, receipt or evaluation of insurance applications or prospective applications of the insurance companies listed at the bottom of this page and their re‐insurers as well as the Representative and its staff, employees and affiliated companies. This authorization shall be valid for twelve (12) months from the date below. A copy of this authorization shall be as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that I may write to the Representative to revoke this authorization and that the revocation will take effect when the Representative receives my written request. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I also understand that, to the extent that other law allows an insurance company listed below to contest a claim under an insurance policy or the insurance policy itself, my revocation of this authorization may not be effective. I understand that if I refuse to sign this authorization, the Representative may not be able to provide full and complete information about the insurance coverage and its cost that may be available to me. I also understand and acknowledge that each of the insurers listed on this form, or to which I may formally apply, may require me to sign a similar authorization used exclusively by such insurer before they will process my application or offer insurance coverage. I understand that my refusal to sign this authorization will not affect my ability to obtain treatment or payment for services, or my eligibility for health care benefits; provided, however, that if a health care service (e.g, a physical exam) is requested solely for the purpose of creating protected health information to be disclosed to a third party, the health care provider may refuse to provide the service if I do not sign this authorization.
Let's Get Started...
Please answer the following form to the best of your ability. Do know, the form is quite lengthy and you may need 60 minutes to complete on average.
Name of the Proposed Insured's Name
*
First
Last
Proposed Insured’s Signature
*
If a touch interface is not available, signing your name with a mouse will work.
Signed and Dated On:
*
MM slash DD slash YYYY
At (City, State, Zip Code)
*
Name
*
First
Last
Gender:
*
Male
Female
Date of birth:
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Phone
*
Height:
5'6"
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Weight in LBs:
*
Any Weight Change in Last Year: +/- 10 lbs?
*
Yes
No
What was your weight (in LBS) 12 months ago?
Reason for the weight change?
Ever Used Tobacco:
*
No
Cigarettes
E-Cigarettes
Cigars
Chewing Tobacco
Patch/Gum
Marijuana
Cigarettes, please indicate frequency:
E-Cigarettes, please indicate frequency:
Cigars, please indicate frequency:
Chewing Tobacco, please indicate frequency:
Patch/Gum, please indicate frequency:
Marijuana, please indicate frequency:
Cigarettes, date Last Used:
MM slash DD slash YYYY
E-Cigarettes, date Last Used:
MM slash DD slash YYYY
Cigars, date Last Used:
MM slash DD slash YYYY
Chewing Tobacco, date Last Used:
MM slash DD slash YYYY
Patch/Gum, date Last Used:
MM slash DD slash YYYY
Marijuana, date Last Used:
MM slash DD slash YYYY
Had Any of The Following:
*
No
DUI
Speeding Ticket
Felony Conviction
Pilots License
DUI, provide dates, details:
Speeding Ticket, provide dates, details:
Felony Conviction, provide dates, details:
Pilots License, provide dates, details:
How many times have you traveled outside continental U.S. in past 2 years?
No travel outside the U.S.
One time
Two times
Three times
Four times
Five times
6+ times
First trip: Please include more details like location and approximate dates:
Second trip: Please include more details like location and approximate dates:
Third trip: Please include more details like location and approximate dates:
Fourth trip: Please include more details like location and approximate dates:
Fifth trip: Please include more details like location and approximate dates:
Sixth trip: Please include more details like location and approximate dates:
Do you have tickets purchased to go out of the Continental U.S. or Canada in the next two years?
*
Yes
No
Please include more details:
Do you plan to travel outside continental U.S. in next 2 years?
*
Yes
No
Please include more details:
Approximate Date of Most Recent Physical Exam with Blood Work Completed (Month/Year):
*
Please list any medical or family history worth noting.
Current Medical Conditions
Please list any current medical conditions for which you have been diagnosed or being treated with:
Would you like to add a pre-existing condition?
Yes
No
Condition 1.
Condition 1: Please explain any treatment, medical procedures or surgeries associated with this condition while including start and end dates.
Would you like to add a second pre-existing condition?
Yes
No
Condition 2.
Condition 2: Please explain any treatment, medical procedures or surgeries associated with this condition while including start and end dates.
Would you like to add third pre-existing condition?
Yes
No
Condition 3.
Condition 3: Please explain any treatment, medical procedures or surgeries associated with this condition while including start and end dates.
Would you like to add a fourth pre-existing condition?
Yes
No
Condition 4.
Condition 4: Please explain any treatment, medical procedures or surgeries associated with this condition while including start and end dates.
Medical procedures
Below, please list any medical procedures you have had completed or been advised to have completed:
Would you like to add a medical procedure?
Yes
No
Medical Procedure 1:
Please include details for the above procedure including reason, date, and was the issue resolved?
Would you like to add a second medical procedure?
Yes
No
Medical Procedure 2:
Please include details for the second procedure including reason, date, and was the issue resolved?
Would you like to add a third medical procedure?
Yes
No
Medical Procedure 3:
Please include details for the third procedure including reason, date, and was the issue resolved?
Would you like to add a fourth medical procedure?
Yes
No
Medical Procedure 4:
Please include details for the fourth procedure including reason, date, and was the issue resolved?
Prescriptions
Below, please list all prescriptions you are currently taking or have taken in the last 10 years:
Would you like to add a prescription?
Yes
No
Name of first prescription:
The first prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a second prescription?
Yes
No
Name of second prescription:
The second prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a third prescription?
Yes
No
Name of third prescription:
The third prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a fourth prescription?
Yes
No
Name of fourth prescription:
The fourth prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a fifth prescription?
Yes
No
Name of fifth prescription:
The fifth prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a sixth prescription?
Yes
No
Name of sixth prescription:
The sixth prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a seventh prescription?
Yes
No
Name of seventh prescription:
The seventh prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a eighth prescription?
Yes
No
Name of eighth prescription:
The eighth prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a ninth prescription?
Yes
No
Name of ninth prescription:
The ninth prescription is/was taken for which condition? Dosage? Length Taken?
Would you like to add a tenth prescription?
Yes
No
Name of tenth prescription:
The tenth prescription is/was taken for which condition? Dosage? Length Taken?
Is the client interested in disability insurance?
Yes
No
Occupation
Job Title
Base Salary
Please include any Bonus Salary or Variable Compensation options here:
Brief Description of Duties:
List of Professional Memberships, Designations, Etc.:
Do You Have Disability Insurance:
No
Group
Individual
Please include copy of policy(ies):
Max. file size: 2 MB.
Is the client interested in life insurance?
Yes
No
Do You Currently Have Life Insurance?
Yes
No
Name of Carrier:
Policy Number:
Life Insurance type:
Term
UL
WL
Annual Premium:
Death Benefit:
Policy Date:
MM slash DD slash YYYY
Would you like to add a second life insurance policy?
Yes
No
Name of second Carrier:
Second Policy Number:
Second Life Insurance type:
Term
UL
WL
Second Annual Premium:
Second life insurance death benefit:
Second life insurance policy date:
MM slash DD slash YYYY
Family History: To your knowledge, is there any family history (parent or siblings) with history of cardiovascular disease, cerebrovascular disease, diabetes, or cancer??
Yes
No
Which relative (parent or sibling) had/has a history of cardiovascular disease, cerebrovascular disease, diabetes, or cancer?
Select All
Father
Mother
Siblings
Provide age at onset and a complete diagnosis of your father:
Did your father pass from this diagnosis?
Yes
No
What was your father's age when deceased?
Provide age at onset and a complete diagnosis of your mother:
Did your mother pass from this diagnosis?
Yes
No
What was your mother's age when deceased?
Provide full detail with impairment, age at onset and age at death if deceased of your sibling:
Did your sibling pass from this diagnosis?
Yes
No
What was your sibling's age when deceased?
Is the client interested in long-term care insurance?
Yes
No
Currently Receiving or Have Received Physical Therapy within the past 12 months?
Yes
No
Describe the therapy type and include completion date:
Have You Been Diagnosed with a CVA, Stroke, or TIA?
Yes
No
CVA, Stroke or TIA: Please provide approximate date happened, age at onset, quality of life after & age of death if deceased:
Describe the therapy type and include completion date:
Any Hospitalizations in the Past 5 Years:
Yes
No
Please provide dates & details of your hospitilizations:
Have Your Parents or Siblings Been Diagnosed with Coronary Artery Disease or Dementia?
Yes
No
Coronary Disease: Please provide approximate date happened, age at onset & age of death if deceased:
Have you ever or are you currently receiving payments for disability?
Yes
No
Please list reason & source of disability payment:
Have you ever been declined for LTC?
Yes
No
Please provide carrier, date & reason(s) your LTC purchase was declined:
Do you currently have a handicap parking sticker, placard, or license plate?
Yes
No
Please provide details about your handicap sticker: