Life Insurance Questionnaire

First Name *

Middle Name

Last Name *

Date of Birth

Gender

Male

Female

Other

Height

Weight (lbs)

Explain Gender

Current Occupation

Primary Phone

Cell Phone

Email *

Address

City

State

Zip

State of Residence

State of Birth

Country of Birth (If Not U.S.)

U.S. Citizen / Permanent Resident / Green Card Holder

Yes

No

Aproximate Annual Income

Country Of Citizenship

Visa

WHAT AMOUNT OF DEATH BENEFIT WOULD YOU LIKE US TO QUOTE?

Life Insurance Quote 1

Death Benefit $

Type of Life Insurance

Life Insurance Quote 2

Death Benefit $

Type of Life Insurance

Life Insurance Quote 3

Death Benefit $

Type of Life Insurance

Life Insurance Quote 4

Death Benefit $

Type of Life Insurance

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING

NAME OF MEDICATION/ DATE STARTED/ CONDITION/REASON AND & DATE OF DIAGNOSIS/ DOSAGE/ FREQUENCY

Medication 1

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 2

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 3

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 4

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 5

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 6

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

PLEASE LIST ANY DIAGNOSED/KNOWN HEALTH ISSUES OR RELEVANT HEALTH INFORMATION

PLEASE LIST DETAILS OF ANY SURGERIES YOU HAVE UNDERGONE AND DATE(S)

ARE YOU NOW OR IN THE PAST 7 YEARS HAVE YOU SEEN/CONSULTED WITH A PSYCHIATRIST OR PSYCHOLOGIST?

Yes

No

IF YES, PLEASE NOTE REASON, TREATMENT AND DATE OF LAST SERVICE

Have you been hospitalized due to mental health?

Yes

No

IF YES, PLEASE NOTE REASON, TREATMENT AND DATE OF HSPITALIZATION

FAMILY HISTORY

Does either parent or any sibling have a history of CARDIOVASCULAR disease which was diagnosed BEFORE AGE 70?

Father

Mother

Sibling(s)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Father)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Mother)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Siblings)

Does either parent or any sibling have a history of CANCER which was diagnosed BEFORE AGE 70?

Father

Mother

Sibling(s)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Father)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Mother)

PLEASE LIST: TYPE/ AGE OF DIAGNOSES/ DECEASED (Y/N)/ AGED DECEASED

TYPE OF CARDIOVASCULAR DIAGNOSIS (Siblings)

Are You Considering Replacing Your Current Insurance Policy?

Yes

No

Company Name

Amount of Coverage

Type of Life Insurance

Cache Value

Policy Date

Have You Used Tabacco Or Tabacco Products In The Last 5 Years?

Yes

No

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last used?

On average, how many per day

Date you last used?

On average, how many per day

Have you ever been treated for or taken medication for any of the following?

None of These

High Cholesterol

Total Cholesterol

HDL Ratio

When Did You Last treated

Are you on any medication to control your cholesterol?

Yes

No

When did you start taking this medications

LDL

HDL

Drug Abuse

Have you ever been treated for drug abuse

Yes

No

When was your most recent tretment?

Alcohol Abuse

Have you ever been treated for alcohol abuse

Yes

No

When was your most recent tretment?

Sleep Apnea

When was you diagnosed with sleep apnea?

What was your diagnosis?

Have you received tretmant?

Yes

No

When was the tretment?

Do you use a CPAP machine?

Yes

No

Have you done an overnight sleep study?

Yes

No

Asthma

When was you diagnosed with sleep asthma?

What was your diagnosis?

Have you ever medical treated for asthma?

Yes

No

On average, how many asthma attacks do you have per year?

Have you ever been hospitalized due to asthma?

Yes

No

High Blood Pressure

What is your systolic pressure?

What is your diastolic pressure?

When were you last treated for high blood pressure?

Are you on any medication to controll your blood pressure?

Yes

No

When did you start taking medication to control your blood pressure?

Depression

When whereyou diagnosed with depresion

What was your diagnosis?

Have you ever been hospitalized due to depression?

Yes

No

When was the last hospitalization

Are you currently undergoing treatmant for depression?

Yes

No

Have you ever taken medication or been in psychotherapy for depression?

Yes

No

Are you currently in psychoterapy treatment?

Yes

No

How many different types of medications are you currently taking?

Heart Attack

When were your first diagnosed or treated for a heart attack?

When was your most recent occurrence or episode?

Please enter any other relevant details

Diabetes

Are you currently undergoing treatmants for diabetes?

Yes

No

What is your daily insulin dosage in units?

Most recent A1C

Average A1C last 12 months

Cancer

Type of cancer

Other

When were your first diagnosed or treated?

What was the stage of the cancer?

When were last treated?

Please enter any other relevant details

Anxiety

Please provide with any additional details:

Have you had your drivers license suspended or revoked/suspended or had more then one ticket or accident in the past 5 years?

No

Yes

Have you been convicted of drunk driving (DUI/DWI) in the last 10 years

Yes

No

When was your most recent conviction for drunk driving (DUI/DWI)?

Have you been convicted of reckless driving in the last 10 years?

Yes

No

When was your most recent conviction for reckless driving?

Have your license neeb revoked or suspended in the last 10 years?

Yes

No

When was your most recent conviction resulting in a revoke or suspension?

Have your had any moving violations over the past 5 years?

Yes

No

Total number of moving violations during the last 6 months

Total number of moving violations during the last year, more then 6 months

Total number of moving violations during the last 2 years, more then 1 year ago

Total number of moving violations during the last 3 years, more then 2 years ago

Total number of moving violations during the last 5 years, more then 3 years ago

Please list any additional information you feel might be helpful to use in quoting your insurance

PLEASE LIST DETAILS OF ANY CHILDREN/DEPENDENTS:

1. Name

Date of birth

Relationship

2. Name

Date of birth

Relationship

3. Name

Date of birth

Relationship

4. Name

Date of birth

Relationship

CURRENTLY OWNED LIFE INSURANCE

LIFE INSURANCE POLICY 1

Death Benefit $

Type of Life Insurance

Please select the life insurance company you are using

LIFE INSURANCE POLICY 2

Death Benefit $

Type of Life Insurance

Please select the life insurance company you are using

LIFE INSURANCE POLICY 3

Death Benefit $

Type of Life Insurance

Please select the life insurance company you are using

LIFE INSURANCE POLICY 4

Death Benefit $

Type of Life Insurance

Please select the life insurance company you are using

Who were you referred by?

Relationship to you

Other relatioship

Date

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