Questionnaire
Proposed Insured's Full Name
*
First Name
Last Name
Proposed Insured's Date of Birth?
*
-
Month
-
Day
Year
Date
Relationship to the Proposed Insured?
*
Aunt
Brother
Grandparent
Guardian
Parent
Self
Sister
Spouse
Step-parent
Uncle
Proposed Insured's Gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email Address
*
example@example.com
In the pase 5 years, has the Proposed Insured been diagnosed or treated for any of the following conditions? :
*
Asthma
Cancer
Cardiac disease
Chronic Kidnery Disease
Diabetes
Epilepsy
Hypertension
Psychiatric disorder
HIV/AIDS
N/A
Other
In the past 5 years, has the Proposed Insured been diagnosed or treated for any of the following symptoms? :
*
Cardiac disease
Cardiovascular
Chest pain
Gastrointestinal
Genitourinary
Hematological
Lymphatic
Musculoskeletal
N/A
Neurological
Psychiatric
Respiratory
Weight gain
Weight loss
Other
Is the Proposed Insured disabled, confined to a hospital or nursing facility or require the use of a wheelchair?
*
Yes
No
Do you use any kind of tobacco or have you ever used them (This includes vaping)?
*
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them? Enter N/A if never used.
*
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them? Enter N/A if never used.
*
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Does the Proposed Insured intend to replace or change any existing life insurance policy?
Yes
No
Print Form
Submit
Clear Form
Should be Empty: