LIFE INSURANCE QUESTIONNAIRE
Client Name (Full Name)
*
1. Date of Birth
*
/
Month
/
Day
Year
2. Height
*
3. Current Weight
*
3A) Has your weight changed more than 10 lbs in the last 12 months (gain or loss)
*
Yes
No
4. Face Amount Requested
*
5. Type & Duration (ex: 10, 20, or 30 year Term, Guaranteed U.L., IUL, Whole Life)
*
5A) If Indexed UL when do you want income to start?
6. Will you be replacing current coverage
*
Yes
No
6A) if Yes, then from which company
7. Have you ever been treated for: Blood Pressure:
*
Yes
No
7A) What's your latest BP reading?
8. Have you ever been treated for: Cholesterol:
*
Yes
No
8A) What's your latest Total Cholesterol reading?
9. Have you ever been treated for: Diabetes:
*
Yes
No
9A) Type I or II
9B) Date of onset
/
Month
/
Day
Year
9C) A1C
10. Has any member of your family (siblings and/or parents) been treated for OR died from Cancer, Heart Disease (including heart attack), or stroke, prior to age 60?
*
Yes
No
10A) Relation (sibling or parent)
10B) Age of Onset or Death
10C) what was the ailment (Cancer, Heart Disease, Stroke)
11. Are you currently taking or have been prescribed to take any prescription medication in the last 5 years?
*
Yes
No
11A) Condition
11B) Medication
11C) Condition
11D) Medication
12. Have you used ANY form of Tobacco (cigarettes, nicotine patch, pipe, cigars, dip/chew, nicotine gum, patches, betel nuts) in the last 5 Years:
*
Yes
No
12A) What type of tobacco
13. Have you used ANY form of Tobacco (cigarettes, nicotine patch, pipe, cigars, dip/chew, nicotine gum, patches, betel nuts) in the last 12 Months:
*
Yes
No
13A) What type of tobacco
14. In the past 12 months have you traveled or resided in a foreign country?
*
Yes
No
14A) Country
14B) Time / Length
14C) Reason
14D) Country
14E) Time / Length
14F) Reason
15. Do you have current plans to travel or reside in a foreign country in the next 12-24 months?
*
Yes
No
15A) Country
15B) Time / Length
15C) Reason
15D) Country
15E) Time / Length
15F) Reason
16. Is there anything further medically or other such as: scuba diving, hang gliding, racing, private pilot, parachuting, etc... that you need to disclose which will be material in the underwriting process:
*
17. Will you consider an alternative rate class if you do NOT qualify for Preferred rates?
*
Yes
No
maybe
18. Any final comments or things we should know?
Agents name (Full Name)
*
Agent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Agent's Email
*
example@example.com
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ProVision Brokerage
Solutions to Life's Financial Questions
888-776-7590
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