RIA Shop Request - Risk & Insurance Associates

Please send back to rianewbusiness@barnumfg.com for processing

DOB:(Required)

State:(Required)

Product Applied For (Term, WL, etc):(Required)

Face Amount:(Required)

Medical History:

Build:(Required)

Medications within the last 5 years?:(Required)

Reason for previous decline/rating (including family history):(Required)

Tobacco/Nicotine/Marijuana Use within the last 5 years:(Required)

Yes

Type:(Required)

Frequency:(Required)

Last Used:(Required)

Any additional details regarding significant medical history/tests completed:(Required)

Additional Forms/Information:
**The Part 2 completed by the client with the MM app usually has all the above as well as any significant medical history that we would need to include in a shop.**
** If due to lab results, we would need to see a copy of the completed labs or provide the abnormal values**