A1 - GENERAL INFORMATION
Amount of Insurance:

Type of Insurance

 First Name  

Last Name 

Street: City:
State:      United States Date of Birth: 
Email Address: 
Gender:   Marital Status:
Occupation: Family Income:
Have you lived more than 30 days outside the USA or Canada? ----> how long?
A2 - FAMILY HISTORY
Have both your parents lived longer than age 75?    Have any of your parents or blood related siblings been diagnosed with or died prior to age 60 from any of these diseases (check all that apply with Control-Shift): 
A3 - AVIATION - Complete only if you fly an airplane, glider, or helicopter. Otherwise, GO to A5 - High Risk Sports.
Fly airplanes commercially or for hire ?  -------> Total hours flown:
Annual hours flown: IFR (instrument rated): 
A4 - HIGH-RISK SPORTS - Complete if you participate in high risk sports. Otherwise, Go to A6 - Driving Experience .               
Hazardous Sports? (check all that apply)
Scuba Diving Dives Per Year Maximum Depth
Sky Diving Times Per Year
Hang-gliding Times Per Year
Para-Sailing Times Per Year
Other Specify
A5 - DRIVING EXPERIENCE
Do you drive a car or other motor vehicle?  If No - Go to A7 - Tobacco Use.
How often do you wear seatbelts? 
How many speeding tickets in the past 5 years in excess of 10mph? 
How many DUI or reckless driving violations in the past 5 years? 
A6 - TOBACCO USE
Have you ever used tobacco products?  If No - Go to A8 - Blood Donation.
Do you currently use tobacco products?   no   when stopped
yes  what kind   how often
B1 - BODY SIZE
Current Height   Current Weight  
B2 - MEDICAL STATUS
Highest Blood Pressure reading in the last 6 months: 
Most recent Total Cholesterol reading:    HDL
Current medications taken (both prescribed and over the counter):
Do you now or within the past year had any of the following symptoms that were not evaluated by a medical professional (check all that apply)? 
B3 - ALCOHOL USE
Have you ever used alcohol more than 2 drinks in any day?  If No - Go to B5 - Cancer History.
How often do you drink now? 
How much do you regularly drink per day?
Are you currently a member of AA or a similar support group?  B014_Cancer
B4 - CANCER HISTORY
Have you ever been diagnosed with Cancer?    If No - Go to B6 - Diabetes.
What type (s) of Cancer or Malignancy were you diagnosed with (check all that apply)?
TYPE DATE STAGE/SIZE GRADE METASTASIS REOCCURRED DATE
Bladder 
Breast 
Cervical 
Colon/Rectal 
Melanoma 
Prostate 
Hodgkin's
Other 
Type: Location:
What types of treatment have been used (check all that apply)?
surgical removal  chemotherapy  radiation other-->
When was your last treatment? 
B5 - DIABETES
Have you ever been diagnosed with Diabetes?  If No -Go to B7 - Heart Attacks.
What was the age at the onset of Diabetes?  
What is the method you use for control? 
How often is your blood sugar monitored? 
Which of the following abnormalities have you experienced: (check all that apply)
skin ulceration EKG abnormalities insulin reactions diabetic coma retinopathy
heart trouble protein in urine amputations neuropathy  
What were the results of your last Glycohemoglobin (A1C) test during the past 12 months? 
B6 - HEART ATTACKS
Have you ever been diagnosed with Angina, a Heart Attack, Myocardial Infarction, or had a Coronary Bypass or Angioplasty?  If No - Go to B8 Heart Conditions.
What conditions preceded the Heart Attack (check all that apply)?
chest pain irregular EKG arrhythmia-irregular heart beats irregular stress EKG
Severity of last Heart Attack?  Dates of all Heart Attacks:
What is the highest level of activity that you are capable of performing (check all that apply)?
Level One: heavy labor, handball, cross country skiing, running 8 minute miles
Level Two: shoveling, wood cutting, canoeing, jogging 12 minute miles, swimming crawl stroke, rowing machine
Level Three: carpentry, lawn mowing, doubles tennis, swimming breast stroke
Level Four: sedentary life style (unable to do any levels 1-3)
When was the last cardiac workup (stress EKG, echocardiogram, etc.)?
What were the results of the last cardiac workup?
B7 - HEART CONDITIONS
Have you ever been diagnosed with any other Heart Conditions?  If No - Go to B9 - Psychiatric Conditions.
What was your Heart Condition/Diagnosis (check all that apply)?
heart murmur--> Type: cardiomyopathy--> Type:
left ventricle hypertrophy/cardiac enlargement heart arrhythmias/ irregular heart beats
congestive heart failure other--> Type:
Are you experiencing any current symptoms? --> Describe:
What treatments have been prescribed (check all that apply)? 
none medications--> Describe: 
pacemaker surgery--> When?
B8 - PSYCHIATRIC CONDITIONS
Ever been treated for depression or any other psychiatric conditions? If No - Go to B10 - Other Medical Conditions.
Have you ever been hospitalized for depression or any other mental or psychiatric condition?  --> Reason:   Dates:
Have you attempted suicide in the past 10 years?
Have you missed work in the past 12 months due to psychiatric problems?
Are you currently taking medication for depression? 
B9 - OTHER MEDICAL CONDITIONS
Please list up to 4 other illnesses and medical conditions that MOST EFFECT YOUR LIFE and that you may feel could have an affect on your life expectancy: If NONE - Go to C1 OTHER FACTORS
1. Name: Location: Severity: 
Date Diagnosed: Treatment:
How does it affect you? 
Date of last symptom: Status:
2. Name: Location: Severity: 
Date Diagnosed: Treatment:
How does it affect you? 
Date of last symptom: Status:
3. Name: Location: Severity: 
Date Diagnosed: Treatment:
How does it affect you? 
Date of last symptom: Status:
4. Name: Location: Severity: 
Date Diagnosed: Treatment:
How does it affect you? 
Date of last symptom: Status:
C1 - OTHER FACTORS - Is there anything else that you think may effect how long you live favorably or unfavorably? Please let us know:
D 1. Insurance Agent, CPA or Attorney submitting this information:

First Name:

Last Name:
Street: City:
State:      United States  Phone Number 
Email Address: 

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You should hear back with a tentative preliminary life insurance underwriting assessment within 48 working hours - usually sooner.

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