HFS Easy App

HFS Easy App
Legal Name*

First NameLast Name
Gender*
Date of Birth *

MonthDayYear
Date
Spouse (if married):

First NameLast Name
Gender
Ever used a different name?
Marital Status*

MarriedWidowedDivorcedSeparatedSingleOther
Social Security Number*
State & County of Birth*
Height*
Weight*
Employer*
Occupation*
Income*
Net Worth*
Driver's License or Valid ID: *
Issued State*
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residence change in the last 12 months?*
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
CLIENT: Are you currently hospitalized, bedridden or use medical devices such as: wheelchair, walker, dialysis, machine, oxygen equipment, respirator, stair lift, chair lift, motorized scooter or taking medications Aricept, Exelon, Reminyl or Namenda?*

YesNo
SPOUSE: Are you currently hospitalized, bedridden or use medical devices such as: wheelchair, walker, dialysis, machine, oxygen equipment, respirator, stair lift, chair lift, motorized scooter or taking medications Aricept, Exelon, Reminyl or Namenda?

YesNo
CLIENT: Have you ever been diagnosed by a member of the medical profession as having AIDS, HIV, or ARC disorders or tested positive for antibodies for the AIDS virus?*

YesNo
SPOUSE: Have you ever been diagnosed by a member of the medical profession as having AIDS, HIV, or ARC disorders or tested positive for antibodies for the AIDS virus?

YesNo
CLIENT: Have you ever been diagnosed, treated, tested positive for,or been given professional medical advice for: Alzheimer’s disease, dementia, memory loss, multiple sclerosis, muscular dystrophy, ALS (Lou Gehrig’s disease) Parkinson’s disease, down syndrome, organ transplant (other than kidney) or active cancer?*

YesNo
SPOUSE: Have you ever been diagnosed, treated, tested positive for,or been given professional medical advice for: Alzheimer’s disease, dementia, memory loss, multiple sclerosis, muscular dystrophy, ALS (Lou Gehrig’s disease) Parkinson’s disease, down syndrome, organ transplant (other than kidney) or active cancer?

YesNo
Has the insured used any form of tobacco in the past 12 months?*

YesNo
If yes, what form(s)? blanksHow often? blank
If No,

Never UsedQuit Using 1 Year AgoQuit using 3 Years AgoQuit using 5+ Years Ago
Has the insured used marijuana in the past 12 months?*

YesNo
Any major medical conditions in the past 10 years?*

YesNo
Beneficiaries
Legal Name: blanks % Splitblank
DOB: blanks Relationship:blank
Legal Name: blanks % Split: blank
DOB: blanks Relationship:blank
Legal Name: blanks % Split: blank
DOB:blanks Relationship: blank
Legal Name: blanks % Split: blank
DOB: blanks Relationship: blank
Owner or Payor - Other than insured, max of 2

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Social Security Number:
Email:
example@example.com
Joint Owner Legal Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:
Social Security Number:
Email:
example@example.com
Preferred Exam Date and Time (if needed):

Type a question

	Primary Doctor	Facility Name	Reason/Last Visit	Results
1
2
3
4

Medical Risk-Related Questions
Has the Proposed Insured EVER been advised of, diagnosed, tested positive for, sought consultation for, or been treated for: cancer, stroke or heart attack (heart disease) by a member of the medical profession?*

YesNo
Has the Proposed Insured, within the past 10 years, been advised of, diagnosed, tested positive for, sought consultation for, or been treated by a member of the medical profession, for:
Seizures, paralysis, mental or nervous disorder, attempted suicide, recurrent dizziness or fainting,cognitive impairment, Alzheimer’s disease or dementia?*

YesNo
Asthma, emphysema, tuberculosis, sleep apnea, chronic bronchitis or chronic respiratory disorder or persistent shortness of breath?*

YesNo
Chest pain, palpitations, high blood pressure, heart murmur, other disorder of the heart or blood vessels?*

YesNo
Hepatitis, intestinal bleeding, colitis, recurrent diarrhea, or other disorder of the stomach, intestines, liver or pancreas?*

YesNo
Any disorder of the kidney, bladder, prostate, breasts or reproductive organs?*

YesNo
Diabetes or any disease or disorder of the thyroid, or other endocrine glands?*

YesNo
Rheumatoid arthritis, muscular dystrophy, multiple sclerosis or disorders of the spinal cord, muscles, bones, back or joints?*

YesNo
Disorder of the eyes, ears, nose, throat, skin, lymph glands or tumor?*

YesNo
Anemia or disorder of the blood?*

YesNo
Has the Proposed Insured, within the past 10 years, been medically diagnosed or treated by a physician as having AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex) or any other immunological disorder?*

YesNo
Has the Proposed Insured within the past 10 years:
Used heroin, cocaine, marijuana, barbiturates, prescription pain killers or any illegal or controlled substance except as prescribed by a physician?*

YesNo
Been advised to seek, or received counseling or treatment, or attended or joined any organization for alcohol or drug use or abuse?*

YesNo
Has the Proposed Insured within the past 5 years:
Been diagnosed or treated for a mental or physical disorder, illness, injury or surgery by a member of the medical profession?*

YesNo
Had a checkup or other consultation with any doctor, medical practitioner or member of the medical profession?*

YesNo
Been a patient in a hospital, clinic, medical center or other medical facility?*

YesNo
Had any EKG, stress test, blood, urine or other bodily fluid test, or other diagnostic tests (not including HIV tests)?*

YesNo
Been advised to have any diagnostic test (not including HIV tests), hospitalization or surgery which was not completed?*

YesNo
Requested or received a pension, benefits, or payment because of an injury, sickness or disability?*

YesNo
Taken any herbal remedies or been treated with any alternative or complimentary medicine?*

YesNo
Prescriptions: (Name - Dosage)
Signature*

Clear
Signature

Clear
Should be Empty:

HFS Easy App

Beneficiaries

Medical Risk-Related Questions

Has the Proposed Insured, within the past 10 years, been advised of, diagnosed, tested positive for, sought consultation for, or been treated by a member of the medical profession, for:

Has the Proposed Insured within the past 10 years:

Has the Proposed Insured within the past 5 years: