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Harbor Life Questionnaire
Questionnaire
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  • 6
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  • 7
    Select Carrier
    • Select Carrier
    • 5Star Life Insurance Company
    • AARP
    • Acacia Life
    • Accordia Life Insurance
    • AEGON
    • Aetna
    • Aflac
    • AICPA
    • AIG Direct
    • Allianz Insurance
    • Allstate
    • American Amicable
    • American Automobile Association (AAA)
    • American Equity
    • American Family Insurance
    • American Fidelity Life Insurance Company
    • American General Life Insurance Company
    • American Income Life
    • American International Group
    • American Memorial
    • American National Insurance Company
    • American United Life (AUL)
    • Americo Life
    • Ameriprise Financial
    • Ameritas
    • Assurity Life Insurance Company
    • AXA Equitable Life Insurance Company
    • Bankers Life and Casualty Company
    • Banner Life
    • Berkshire Life Insurance Company
    • Boston Mutual
    • Brighthouse Financial
    • Christian Fidelity
    • Cincinnati Insurance
    • CMFG Life Insurance Company
    • CNO Financial Group
    • Colonial Life
    • Colonial Penn
    • Combined Insurance
    • Columbian Mutual Life
    • Columbus Life Insurance Company
    • Connecticut Mutual Life Insurance
    • CUNA Mutual
    • Delaware Life
    • EMC National Life Company
    • Equitrust Life Insurance Company
    • Erie Insurance
    • Family Life Insurance
    • Farm Bureau Insurance
    • FEGLI
    • Fidelity Life Association
    • Farmers Insurance Group
    • Fidelity Security Life Insurance Company
    • First United American
    • Foresters
    • Forethought Life Insurance
    • GEICO
    • Genworth Financial
    • Gerber Life Insurance Company
    • Globe Life
    • Great American Insurance
    • Great-West Financial
    • Great Western Insurance Company
    • Guarantee Trust Life
    • Guardian Life Insurance Company
    • Horace Mann
    • The Hartford
    • Illinois Mutual
    • ING Life Insurance
    • Investor Heritage
    • Jackson National
    • John Hancock Insurance
    • Kansas City Life Insurance Company
    • Kemper Corporation
    • Knights of Columbus
    • LaFayette Life
    • Legal & General America
    • Liberty Bankers
    • Liberty Mutual
    • Life Insurance Company of Alabama
    • Lincoln Financial Group
    • Lincoln Heritage Life Insurance
    • Madison National
    • Manhattan Life Insurance Company
    • MassMutual
    • MetLife
    • Midland National
    • Minnesota Life
    • Motorists Life Insurance
    • Mutual of Omaha
    • Mutual Trust Life Insurance
    • National Guardian Life
    • National Income Life
    • National Life Group
    • Nationwide Life Insurance Company
    • Navy Mutual
    • New Era Life
    • New York Life Insurance Company
    • North American Company for Life and Health
    • North American Insurance Company
    • Northwestern Mutual Life Insurance Company
    • Ohio National
    • Oxford Life Insurance
    • Pacific Life
    • Pan-American Life
    • Penn Mutual
    • Petersen International Underwriters
    • Phoenix Life
    • Physicians Mutual
    • PolicyGenius
    • Primerica
    • Principal Financial Group
    • Progressive Life
    • Protective Life Insurance Company
    • Prudential Financial
    • Riversource Life
    • Sagicor Life Insurance
    • Royal Neighbors of America
    • Savings Bank Life Insurance (SBLI)
    • Securian Life Insurance Company
    • Security Life of Denver Insurance Company
    • Security Mutual Life Insurance Company of New York
    • Security National Life Insurance Company
    • SelectQuote
    • Senior Life Insurance Company
    • Sentinel Security Life Insurance Company
    • Servicemembers Group Life Insurance
    • Settlers Life
    • Shelter Insurance Companies
    • Southern Farm Bureau Life Insurance Company
    • Sun Life Financial
    • Standard Insurance Company
    • Standard Life and Casaulty
    • Starmount Life Insurance Company
    • State Farm Life Insurance
    • Symetra Life Insurance Company
    • Thrivent Financial
    • TIAA-CREF
    • Transamerica Corporation Insurance Company
    • United American Insurance Company
    • United Home Life
    • United of Omaha
    • Unum Group
    • USAA Life Insurance
    • Vantis Life Insurance
    • Veterans Group Life Insurance
    • VOYA Life Insurance
    • Washington National Insurance Company
    • West Coast Life
    • Western and Southern Life Assurance Company
    • William Penn Life Insurance
    • WoodmenLife
    • Other-Carrier Not Listed
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  • 8
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  • 10
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  • 11
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Select an Option
    • Select an Option
    • Healthy or average
    • Minor (ex. diabetes)
    • Terminal (ex. cancer)
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  • 24
    Please enter your height in ft and inches:
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    Please enter your weight in lbs
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    If you don't know, or you don't have high blood pressure, use 120/80
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    Also called atherosclerosis, this is the buildup of plaque & deposits in your arteries
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  • 34
    This includes all coronary procedures & surgeries, but NOT diagnostic tests like EKGs, or stress tests.
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    Do you have a problem with any of your heart valves?
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    Pulmonary hypertension is a type of high blood pressure that affects the arteries in your lungs and the right side of your heart.
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    Atrial fibrillation (or Afib) is an irregular heartbeat.
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    TIA (transient ischemic attack) is sometimes called a mini-stroke.
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    Carotid disease is the blocking or narrowing of your carotid artery
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    PVD is a blood circulation disorder that pain and fatigue in your legs. 
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    Steroidal inhalers include Flovent, Pulmicort, Advair, Dulera
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  • 65
    Diabetic neuropathy is nerve damage/pain due caused by diabetes. This question also includes ulcers or sores on your feet/legs due to diabetes.
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    Diabetic nephropathy is kidney disease caused by diabetes.
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    Diabetic retinopathy causes eye and vision problems due to diabetes.
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    Thrombocytopenia is low levels of blood platelets. Thrombocytosis is too many platelets in your blood which increases risk of blood clots.
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    Polycythemia vera is a type of blood cancer that causes too many platelets, and increasing risk of blood clots.
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    MGUS causes elevated M protein in your blood.
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  • 89
    Both of these disorders cause disruptions in the production of blood cells or cause them to grow abnormally.
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  • 90
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    This is sometimes called acute non-lymphocytic leukemia. It affects the blood & bone marrow. If your cancer has spread to other organs, please select stage 4.
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  • 94
    If your cancer has spread to other organs, please select stage 4.
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    Includes all types of bone cancers, also called sarcomas. If your cancer has spread to other organs, please select stage 4.
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    Includes all types of brain cancers such as astrocytomas, meningioma, and gliomas. If your cancer has spread to other organs, please select stage 4.
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    If your cancer has spread to other organs, please select stage 4.
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  • 101
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  • 102
    CLL & CML are types of blood cancer. If your cancer has spread to other organs, please select stage 4.
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  • 104
    If your cancer has spread to other organs, please select stage 4.
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  • 106
    If your cancer has spread to other organs, please select stage 4.
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  • 107
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  • 108
    If your cancer has spread to other organs, please select stage 4.
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  • 109
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  • 110
    Sometimes called Hodgkin's disease. If your cancer has spread to other organs, please select stage 4.
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  • 111
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  • 112
    If your cancer has spread to other organs, please select stage 4.
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  • 113
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  • 114
    Cancer of the larynx (voicebox). If your cancer has spread to other organs, please select stage 4.
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  • 116
    If your cancer has spread to other organs, please select stage 4.
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  • 117
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  • 118
    If your cancer has spread to other organs, please select stage 4.
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  • 119
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  • 120
    If your cancer has spread to other organs, please select stage 4.
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  • 121
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  • 122
    If your cancer has spread to other organs, please select stage 4.
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  • 123
    If your cancer has spread to other organs, please select stage 4.
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  • 124
    Cancer of the blood plasma. If your cancer has spread to other organs, please select stage 4.
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  • 125
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  • 126
    If your cancer has spread to other organs, please select stage 4.
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  • 127
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  • 128
    If your cancer has spread to other organs, please select stage 4.
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  • 129
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  • 130
    If your cancer has spread to other organs, please select stage 4.
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  • 131
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  • 132
    Any cancers not otherwise listed. If your cancer has spread to other organs, please select stage 4.
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  • 133
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  • 134
    If your cancer has spread to other organs, please select stage 4.
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  • 135
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  • 136
    If your cancer has spread to other organs, please select stage 4.
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  • 137
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    May be called liposarcoma or malignant schwannoma. If your cancer has spread to other organs, please select stage 4.
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  • 139
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  • 140
    If your cancer has spread to other organs, please select stage 4.
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  • 141
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  • 142
    If your cancer has spread to other organs, please select stage 4.
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  • 143
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  • 144
    If your cancer has spread to other organs, please select stage 4.
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  • 145
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  • 146
    This question is asking about major memory loss requiring medication. 
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  • 156
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  • 157
    Do you have ongoing issues with walking/balance?
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  • 158
    Have you fallen more than once in the last 6 months? 
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  • 159
    Do you use an assistive device occasionally or all the time?
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  • 160
    Do you have poor fine motor skills or difficulty with hand-eye coordination the impacts your daily activities?
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  • 161
    Do you have ongoing problems with memory that are severe or worsening that impacts your daily activities?
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  • 162
    Do you have depression that requires medication or that interferes with your daily activities?
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  • 163
    Do you have vision problems that impact your daily activities?
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  • 164
    Do you have arthritis that impairs your ability to complete tasks on your own?
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  • 165
    Do you have chronic pain that impacts your daily activities?
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  • 166
    Do you need help completing daily tasks such as getting around, bathing, eating, dressing, or using the bathroom?
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  • 167
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