Life Insurance Questionnaire

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Occupation

Education Level

What type of Life insurance are you interested in?

What amount would you be interested in? Check all that may apply

Height? Example:5'7"

Weight?

Sex

Marijuana use? If so how to you consume it? Example NO/Yes Edible form

Tobacco use

If yes, What type? Example Vaping/cigarette/chewing

Where you diagnosed or treated for any medical conditions in the past 10 years? If so, What? Example High Blood pressure/none

What medical conditions are you CURRENTLY receiving treatments for? Example: High blood pressure/none

Have you had surgery in the past years? If so, what type of surgery and what was the outcome of the surgery? Example: Knee replacement. No issues since/None

Do you exercise? If so, what activities and how often? Example: Walking, three times a week.

Where either of your PARENTS OR ANY SIBLINGS diagnosed BEFORE THE AGE OF 60 OF

If yes, who and which condition? What age were they diagnosed? Example: Sister,Colon Cancer, age 50

If so, did they die of that condition? Yes/No

Have you been advised that you have

Do you participate in any high risk adventures? Example: Scuba diving, Skydiving, Racing, Private Pilot. No/ if yes, please list.

Have you had three or more moving violations in the past three years, or a DUI in the past 5 years? If so, please list Approx date, or none

Have you ever been convicted of a Felony?

Are you a U.S. Citizen?

Do you plan on traveling outside the U.S. or Canada in the next two years? If so, where and for how long?

I will need to run a insurance credit report is that ok?

Form

Life insurance Questionnaire