Life & Disability Insurance Client Health Questionnaire
Personal information
Please note this is for one applicant per request.
Name
First Name
Last Name
Age
What is YOUR Income annually? (this is needed to determine what you may be approved for on both life and disability)
Height
Weight
Tobacco
Y
N
Cigarettes
Y
N
Life & Disability Product Options
Do you want...
Term Life 10 year (lower cost, expires year 10)
Term Life 20 year (lower cost, expires year 20)
Term Life 30 year (lower cost, expires year 30)
Whole Life (more expensive, does not expire, loans can be drawn on it in later years)
Disability Short Term (90 days)
Disability Long Term (after day 90)
Please put the amount of life insurance you are interested in getting.
Health information
Diabetes
Y
N
Age diagnosed w/Diabetes
Insulin
Y
N
Age started Insulin
Units of Insulin
Fasting sugar reading
A1C reading
Complications
Eye
Kindey
Neoropathy
Insulin shock or Coma
Heart Disease
Y
N
Pace Maker
Y
N
If Y Date Installed
Difibulator
y
N
If Y date installed
Afib/Irrigular Heart Rytham
Y
N
Congestive Heart failure
Y
N
Last Occurance
Nitroglycerin or Patches?
Y
N
Type a question
Stroke
Y
N
Last Occurance
Cancer
Y
N
Last Treatment Date
COPD Lung Disease
Y
N
Oxygen Use
Y
N
Use oxygen 2 times or less per week
Y
N
Sleep Apnea
Y
N
Date Diagnosed
Any Inhalers?
Y
N
Does Tanya Boyd & Associates, LLC (Tanya Boyd, Tammy Ross, Wendy Gant, and/or Kelly Morgan have your permission to be your representative and work on your behalf?
Y
N
Signature
Submit
Should be Empty: