Life Questionnaire
*Social and Drivers License to be obtained offline.
Name of Proposed Insured
*
First Name
Last Name
Amount of Insurance Applying For:
*
Date of Birth:
*
MM/DD/YY
Gender
*
Male
Female
Country of Birth
State of Birth
Drivers License State and Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Phone Number
Format: (000) 000-0000.
Height of Proposed Insured
FT IN
Weight of Proposed Insured
lbs
Employer's Name
Occupation and duties
Years and Months with Current Employer
If Employer Not Applicable, please choose one:
Unemployed
Retired
Student
Homemaker
Juvenile
Disabled
Annual Household Income
If married: Amount of Life Insurance in force or applied for on spouse.
Beneficiary Name
Relationship to Insured (Spouse, Parent, Child, Sibling, etc)
Percentage of Share
If divided between addt'l beneficiaries, total must equal 100%.
For additional Beneficiaries: enter Name, Relationship and Percentage of share
Optional: Will there be a Contingent Beneficiary? Enter Name & Relationship
Have you filed for Bankruptcy in the past SEVEN years?
Yes
No
Primary Purpose of insurance
Personal Needs
Business Needs
Is this a Business related sale?
Yes
No
Do you currently have any Life Insurance in force or a pending application?
Yes
No
YES ONLY, please provide: Company and Face Amount
Will this application reduce or replace current policy?
Yes
No
YES ONLY, please provide: Policy Number
Primary Physician: Name and Phone or Address
Month/Year of Last Visit:
MM/YY
Reason for Dr. Visit:
Have you had an application for Life declined, postponed, or issued other than applied?
Yes
No
Do you plan to travel, work, or reside outside the US in the next TWO years?
Yes
No
YES ONLY, please list: City, Country, Length of Trip, Business or Pleasure
Have you used Tobacco or Nicotine products in the past FIVE years?
Yes
No
YES ONLY, please list: Type of Nicotine/Tobacco and Date Last Used
License Suspension/Revoked, Reckless Driving Conviction, DUI/DWI in the past TEN years?
Yes
No
YES ONLY, please list: Type of Conviction and Year
Any other Driving Convictions in the past FIVE years? Tickets/Accidents?
Yes
No
YES ONLY: number of convictions in past 5 years
1-2
2+
Felony or Misdemeanor in the past TEN years?
Yes
No
YES ONLY, please list: Type, Date, City/State
Are you a member of the Military, Reserve, National Guard? Or have a written agreement to become a member?
Yes
No
YES ONLY, please list: City, Country, and Dates
In the past TWO years, have you flown as a pilot, student pilot, or crewmember? Or plan to within the next two years?
Yes
No
Have in the past TWO years (or plan to): Hang Gliding, Para Sailing, Para Kiting, Parachuting, Skydiving, Ultralight Soaring, Ballooning, Bungee Jumping, Rock/Mountain Climbing, Underwater Diving, Organized Racing by Auto/Motorcycle/ Powerboat/Snowmobile?
Yes
No
YES ONLY, choose type:
Airborne
Motor Racing
Climbing
Scuba
Have you lost more than 15 lbs over the last TWELVE MONTHS?
Yes
No
YES ONLY, please enter: Amount of weight lost and Reason (Diet/Exercise/Illness/Surgery)
Congenital or Birth Disorders: blindness, deafness, missing limbs, heart defect, Downs Syndrome, Autism?
Yes
No
YES ONLY, please enter: Type of Disorder and whether Surgery was necessary
High blood pressure or high cholesterol/hyperlipidemia?
Yes
No
YES ONLY, please enter: Type and any Medication
Chest pain, angina, heart attack, heart murmur, stroke or transient ischemic attack/mini stroke (TIA), irregular heart beat/rhythm, other circulatory or heart disorder or coronary artery / heart disease / atherosclerosis?
Yes
No
YES ONLY, please list: Type, Medications, Last Follow Up w/Physician
Cancer, tumor, mass, skin cancer including melanoma, leukemia, lymphoma, colon polyp, or any malignant or benign growth?
Yes
No
YES ONLY, please enter: Type and Date of Release/Remission
Diabetes, impaired glucose tolerance (pre-diabetes), gestational diabetes, anemia or other blood disorder (excluding HIV), or disease or disorder of the thyroid, pituitary or adrenal glands?
Yes
No
YES ONLY, please enter: Type and Medication
Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery?
Yes
No
YES ONLY, please enter: Type and Medication
Depression, anxiety, stress, eating disorder (anorexia or bulimia), post-traumatic stress, attention deficit/attention deficit hyperactivity, bipolar or other psychiatric or mental health disorder?
Yes
No
YES ONLY, please enter: Type and Hospitalization in the past THREE years?
Seizures, paralysis, multiple sclerosis, memory loss or other disease or disorder of the nervous system?
Yes
No
YES ONLY, please enter: Type and Medication
Asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder of the lungs or respiratory system?
Yes
No
YES ONLY, please enter: Type and Medication, Hospitalization in the past FIVE years?
Kidney, bladder, urinary, reproductive organ (other than contraceptive medication) or prostate disorder?
Yes
No
YES ONLY, please enter: Type and any Medication or Surgery?
Arthritis, fibromyalgia, gout, back or joint pain or muscle disorder, or Lupus?
Yes
No
YES ONLY, please enter: Type and any Medication or Surgery?
In the past FIVE years, have you been treated for, been hospitalized for, or diagnosed as having Human Immunodeficiency Virus (HIV) antibodies or antigens or Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
Yes
No
Ever used, or been treated for the use of amphetamines, barbiturates, cocaine, marijuana, opiates, hallucinogens or any other illegal drugs or have you been treated or abuse of prescription drugs?
Yes
No
YES ONLY, please enter: Drug and Last Date Used
Ever been advised by a medical professional to reduce or stop drinking alcohol, or received treatment of any kind for the use of alcohol?
Yes
No
YES ONLY, when we you advised?
within past 2 years
3 - 5 years
5+ years ago
Do you currently drink alcoholic beverages? How much per week?
No, I do not drink
1-7 drinks
8-14 drinks
15-19 drinks
20-25 drinks
26-35 drinks
In the past FIVE years, have you been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
Yes
No
YES ONLY, please enter: Reason, Dates, and any Medication
Have you, in the past FIVE years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test that are not included in your answers to any of the preceding questions?
Yes
No
YES ONLY, please enter: Diagnosis and Date of Release
Ever attempted Suicide?
Yes
No
YES ONLY, attempt occurred:
Past 12 months
1-5 years ago
5+ years ago
Other
FAMILY HEALTH
Age of Parent 1:
Status
Living
Deceased
Unknown
Age of Parent 2:
Status
Living
Deceased
Unknown
Age of Sibling 1:
Status
Living
Deceased
Unknown
Age of Sibling 2:
Status
Living
Deceased
Unknown
Additional Siblings, please list: Age and Status (living/deceased/unknown)
Any of the above family members suffer from: Alheimer's, Cancer, Heart Disease, Familial Adenomatous, Huntingtons, ALS.
none of the above
parent 1
parent 2
silbing 1
sibling2
JUVENILE LIFE APPLICATIONS ONLY
Additional info required for ages 17 and under
Owner's Name
Owner's Birthdate
-
Month
-
Day
Year
Date
Co-Owner Name
First Name
Last Name
Co-Owner Birthdate
-
Month
-
Day
Year
Date
How many parents live in the same household?
Amount of Life Insurance on both parents (including new Life applications)
How many siblings (Ages 17 and under) are in the same household?
Ages of Siblings
Amount of Life Insurance on Siblings (including new Life applications)
Submit
Should be Empty: