Matt Sells | Life Insurance Questionnaire

Medical Information
Height*
Weight*
Tobacco or Nicotine Use:*
Type:*
How Often:*
Current Medications*
Has either parent, or any sibling, died or been diagnosed before the age of 60 or 65 from cancer or heart disease?*
If Yes (list cause, relationship, and age at death)
Personal Medical History: *
(list and past or current health conditions/diseases/surgical procedures, include dates of treatment and type of treatment, list any current medications)
Please list any other illness or impairment *
(list and past or current health conditions/diseases/surgical procedures, include dates of treatment and type of treatment, list any current medications)

Underwriting Questions
Bankruptcy*
Coverages
Type of Policy*
Desired Amount of Coverage*
Current Insurance In-force*
UL/WL, Term, or Other * Please provide copies of existing policies and/or annual statements
Cancelof
Agency Contact Information
Meridian Insurance
7601 Paragon Road ∙ Suite 203 ∙ Dayton, OH 45459
Phone: (800) 207-7079 ∙ Fax: (937) 567-8999
Should be Empty:

Life Insurance Questionnaire