Symmetry Carrier Matcher

Client Info

Tobacco

Health

Medications

Coverage

Client Demographics

Basic info used to calculate BMI, check age eligibility, and narrow product options.

Client Name (optional)

Date of Birth / Age Enter age instead

/ /

Enter current age in years

Gender

Height

Weight (lbs)

Tobacco & Nicotine Use

Carrier tobacco classification varies widely. Foresters ignores vaping/chewing; Americo gives non-smoker rates for 3 years.

Current nicotine/tobacco use

🚫 None (24+ months)

🚬 Cigarettes

💨 Vaping / E-Cigs

🌿 Chewing / Snuff

🔥 Cigars / Pipe

💊 Patch / Gum / Lozenge

✅ Quit (within 1-2 yrs)

🚬 Cigarette / Recent Quit Details

How long have they used/smoked?

Quit status

Medical History

Select all that apply. Detailed follow-ups will appear for conditions that need more info.

Select all conditions that apply:

🩸 Diabetes

❤️ Heart Disease / Attack / Angina

🎗️ Cancer (history)

🧠 Stroke / TIA

🫁 COPD / Emphysema

💊 Depression / Anxiety

🔄 Bipolar Disorder

🧩 Schizophrenia / Psychosis

😴 Sleep Apnea / CPAP

⚗️ Thyroid Removed

🦶 Neuropathy

🫘 Kidney Disease / Dialysis

💉 HIV / AIDS

🏥 Organ Transplant

🧓 Alzheimer's / Dementia

🤚 Parkinson's Disease

🔵 Multiple Sclerosis

🌺 Lupus (Systemic)

⚖️ Felony Conviction

👶 Insuring a Child

🛁 Needs ADL Assistance

🏠 Hospice / Oxygen Use

⚡ ALS / Lou Gehrig's

💔 Congestive Heart Failure

🩸 Diabetes Details

Type

Age at diagnosis

Last A1C reading

Insulin dependent?

No oral meds only

Yes, uses insulin

Complications? (neuropathy, retinopathy, nephropathy)

None

1 complication

2+ complications

💊 Depression / Mental Health Details

Any psychiatric hospital stays or suicide attempts?

Yes

Currently taking Paxil or Trazodone?

Yes

😴 Sleep Apnea Details

CPAP with or without supplemental oxygen?

CPAP only (no oxygen)

Uses supplemental oxygen

🎗️ Cancer Details

Is it metastatic / multiple occurrences?

No / single occurrence

Yes / metastatic

When was last cancer diagnosis/treatment?

❤️ Heart Condition Details

Did they have any cardiac procedure in the last 2 years? (bypass, stent, ablation, etc.)

Yes, within 2 years

Medications

Rule of thumb: 3+ medications for one diagnosis = whole life. Certain medications are automatic declines at some carriers.

List current medications (optional — one per line)

🔍 Live Drug Recognition

3+ meds for any single diagnosis?

Yes — whole life territory

Taking blood thinners? (Xarelto, Eliquis, Warfarin, Plavix, Pradaxa)

Yes

⚠️ Auto-decline medications at Express/Simplified carriers: Lithium, Methadone, Clozapine, Coumadin/Warfarin, Digoxin, Lovenox, Eliquis, Xarelto, Pradaxa, Plavix (may disqualify Express Term/IUL at MOO). Check carrier Rx guides for full lists.

Coverage Needs

What the client wants — face amount and product type narrow the best carrier fits.

Desired face amount (coverage)

Product type preference

Preferred term length (if term)

Living benefits needed?

Yes, required

Nice to have

Not a priority

Client notes (optional)

Carrier Recommendations

Based on client profile, Symmetry cheat sheet, and carrier underwriting guidelines