Term Life / Critical Illness Fact Finder

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

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Date of Birth*

Date

Gender*

MaleFemale

Email

example@example.com

Phone Number

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1) In the l‌ast 5 y‌ears, have any of the proposed insureds participated in any motorized or non-motorized vehicle racing (includes stunt show or speed test, drivers, pit crew, owners or mechanics) or any of the following activities: boxing, hot-air ballooning, parkour, free running, extreme sports, skydiving, ultra light flying, parachute jumping, hang gliding, parakiting, sail gliding, scuba diving, rock or mountain climbing? (Please answer question "No" if one-time event with no future participation.)*

YesNo

2) In the l‌ast 3 y‌ears, has any proposed insured flown as a pilot, crew member or student, or planning such activity in the next 12 m‌onths?*

YesNo

3) In the l‌ast 5 y‌ears, have any of the proposed insureds pled guilty to or been convicted of operating a motor vehicle under the influence of alcohol or drugs, pled guilty to or been convicted of more than 3 moving violations or had their driver's license suspended or revoked?*

YesNo

In the l‌ast 10 y‌ears, has any proposed insured pled guilty to or been convicted of a felony or are felony charges now pending?*

YesNo

Are you or any applicant over 300 pounds if male, or over 250 pounds if female?*

YesNo

6) Has any proposed insured; been seen in the past y‌ear by, or been referred to, or have a pending appointment to see any of the following specialists?

Cardiology / Cardio vascular surgeon (heart and vascular specialist)
Hematology (blood, blood forming organs and lymph nodes specialist)
Neurology / Neurosurgeon (nervous system specialist)
Endocrinology (endocrine organs / hormonal disorder specialist)
Oncology (cancer specialist)

Question 6*

YesNo

7) In the l‌ast 10 y‌ears has any proposed insured: *

Been hospitalized for high blood pressure or any mental nervous disorder?
Received or recommended to have any treatment for alcoholism, alcohol or drug abuse or addiction, including but not limited to, counseling or attendance at support groups?
Used illegal drugs or prescription medication other than as prescribed or been advised by a member of the medical profession to discontinue or decrease alcohol consumption or drug use?

Question 7*

YesNo

Has any proposed insured ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for any of the following conditions?

Heart disorders
Coronary Artery Disease (CAD)
Heart Attack or Myocardial Infarction (MI)
Angina Pectoris
Congestive Heart Failure (CHF)
Atrial Fibrillation
Stroke (cerebral vascular accident)
TIA (Transient Ischemic Attack)
Emphysema or Chronic Obstructive Pulmonary Disease (COPD)
Peripheral Vascular Disease (PVD), Peripheral Arterial Disease (PAD)
Crohn's Disease or Ulcerative Colitis
Liver Disease, excluding fully recovered Hepatitis A
Kidney disorders, excluding kidney stones
Portal Hypertension
Pulmonary Fibrosis, Cystic Fibrosis
Alzheimer's Disease
Dementia
Blood Disorders
Systemic Lupus Erythematosus
Tuberculosis (TB)
Diabetes
Cancer or Tumor/Mass
Leukemia
Melanoma
Skin Cancer (2 or more occurrences)
Hodgkin lymphoma or non-Hodgkin lymphoma (NHL)
Alcoholism, Alcohol or Chemical Dependency, or Drug or Alcohol Abuse
Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human
Immunodeficiency Virus (HIV)
Multiple Sclerosis (MS)
ALS (Amyotrophic Lateral Sclerosis)
Paralysis
Organ or stem cell transplant
Bipolar Disorder or Schizophrenia

9) In the last 12 months, has any proposed insured been bedridden, confined to a hospital, nursing home, mental facility, inpatient rehabilitation, subacute facility, or hospice?*

YesNo

10) In the l‌ast 12 m‌onths, has any proposed insured:

been recommended or scheduled for diagnostic testing (excluding tests related to HIV or AIDS), consultations, treatment, follow-up or surgery by a member of the medical profession that has not been completed?
had any testing (excluding tests related to HIV or AIDS)with abnormal findings?
had tests (excluding tests related to HIV or AIDS)for which you have not received results?
had any unexplained: weight loss, anemia, chronic fatigue, chest pain, shortness of breath, palpitations, chronic cough, gastrointestinal bleeding, lumps in the breast, dizziness or loss of consciousness?

Question 10*

YesNo

11) Has any proposed insured’s natural parents, brothers or sisters, either living or deceased, been diagnosed by a member of the medical profession, prior to age 60, with any of the following conditions: Cancer, Heart Disease, Huntington's Disease?*

YesNo