Life Settlement Questionnaire

Insured 1

First Name *

Middle Name

Last Name *

Gender

Male

Female

Other

Date of Birth

Do You UseTabacco Or Tabacco Products?

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

Insured 2

First Name

Middle Name

Last Name

Gender

Male

Female

Other

Date of Birth

Do You UseTabacco Or Tabacco Products?

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

Primary Number

Cell Number

Work Number

Email *

Address

Apt/Suite

City

State

Zip

CURRENTLY OWNED LIFE INSURANCE

Death Benefit $

Type of Life Insurance

Policy Issue Date

Please select the life insurance company you are using

Policy Number

Conversion Deadline Or Lapse Date

Risk Clasic at Which Policy Was Issued

Is There A Loan on Your Policy?

Yes

No

How Much Is the Loan on Your Policy

Have Life Expectancy (LE) Reports Been Obtained?

Yes

No

From Which Provider Did You Obtain the Life Expectancy Report?

DO YOU HAVE SYMPTOMS OF OR WITHING THE LAST 10 YEARS HAVE YOU RECEIVED MEDICAL ADVICE, DIAGNOSIS OR TREATMENT OR CONSULTED WITH A MEMBER OF THE MEDICAL PROFESSION FOR ANY OF THE FOLLOWING CONDITIONS?

Insured 1

Heart Disease

Yes

No

Coronary Artery Disease

Yes

No

Circulatory Disorders

Yes

No

Hypertension

Yes

No

High Blood Pressure

Yes

No

Leukemia

Yes

No

Lymphoma

Yes

No

Cancer

Yes

No

Paralysis

Yes

No

Stroke

Yes

No

Bowel Disorders

Yes

No

Bladder Disorders

Yes

No

Prostate Disorders

Yes

No

Liver Disorders

Yes

No

Diabetes

Yes

No

Depression

Yes

No

Alcoholism

Yes

No

Drug Addiction

Yes

No

Kidney Disorders

Yes

No

Osteoporosis

Yes

No

Arthritis

Yes

No

Reproductive Organ Disorders

Yes

No

Respiratory Disorders

Yes

No

Shortness of Breath

Yes

No

Fainting Spells

Yes

No

Dizziness

Yes

No

Seizures

Yes

No

Tremors

Yes

No

Elevated Cholesterol

Yes

No

Insured 2

Heart Disease

Yes

No

Coronary Artery Disease

Yes

No

Circulatory Disorders

Yes

No

Hypertension

Yes

No

High Blood Pressure

Yes

No

Leukemia

Yes

No

Lymphoma

Yes

No

Cancer

Yes

No

Paralysis

Yes

No

Stroke

Yes

No

Bowel Disorders

Yes

No

Bladder Disorders

Yes

No

Prostate Disorders

Yes

No

Liver Disorders

Yes

No

Diabetes

Yes

No

Depression

Yes

No

Alcoholism

Yes

No

Drug Addiction

Yes

No

Kidney Disorders

Yes

No

Osteoporosis

Yes

No

Arthritis

Yes

No

Reproductive Organ Disorders

Yes

No

Respiratory Disorders

Yes

No

Shortness of Breath

Yes

No

Fainting Spells

Yes

No

Dizziness

Yes

No

Seizures

Yes

No

Tremors

Yes

No

Elevated Cholesterol

Yes

No

PLEASE NOTE YOUR GENERAL LIFESTYLE AND STATE OF HEALTH

I live an active and independent lifestyle, exercise regulary, travel, work, etc. My risk class would be considered standard or better

Insured 1

True

False

Insured 2

True

False

I live independently but DO require assistance and supervision. My risk class would likely be highly rated.

Insured 1

True

False

Insured 2

True

False

I live an average lifestyle, lrimarily independent, but with some minor assistance.. My risk class would be likely be rated a faw tables

Insured 1

True

False

Insured 2

True

False

I DO NOT live independently and require DAILY and/or FULL-TIME supervision. I would not qualify for any new insurance.

insured 1

True

False

insured 2

True

False

I have been diagnosed with a TEMINAL condition, that will result in alife expectancy of 24 months or less

insured_1

True

False

insured_2

True

False

Date

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