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Agent Information:
Name: Email: Phone:
Date:
State:    

Proposed Insured Information:
Name:
Male: Female:
DOB:
  Height:     feet   inches
Weight: lbs.
Additional Insured:   (check if applicable)
Name:
Male: Female:
DOB:
  Height:     feet   inches
Weight: lbs.

Type of Insurance:
Term: Permanent:

  ROP
Death Benefit Amount:    
$    

 
Death Benefit Amount:
$
 
 

Health Rating Requested:
Preferred: Standard:

 

 

BEGIN NON-MEDICAL QUESTIONNAIRE

Non-Medical Questionnaire:
IS/HAS PROPOSED INSURED:
1) Consulted a physician or had treatment for the use or possession of alcohol or narcotics? Yes No

2) In the past 5 years been convicted of major moving violation or had their driver’s license suspended or revoked? Yes No

3) Been convicted of, or pled guilty or no contest to a felony, or do they have any such charge pending against them? Yes No

4) Flown as a pilot, student pilot or crew member? Yes No

5) Active in the military? Yes No

6) Engaged in hazardous activities such as: auto or motorcycle racing, parachuting, skin or scuba diving, skydiving, hang gliding? Yes No

7) Had a request for life insurance declined? Yes No

8) A citizen of any other country besides the U.S.? Yes No

9) Lived outside of North America at any time in the last 3 years? Yes No

10) Intending to travel outside the U.S. or Canada within the next 12 months? Yes No

11) Has the proposed insured or additional insured been treated for any previous or existing medical conditions? Yes No

IS/HAS PROPOSED INSURED EVER BEEN TREATED OR TOLD THEY HAVE:
a) Cancer, diabetes, epilepsy, heart disorder, high blood pressure, stroke, mental or nervous disorders, tumors, ulcers, or any disorder of bladder, kidney, liver or lungs? Yes No

b) Acquired immune deficiency syndrome or ARC (AIDS-related complex)? Yes No

c) Arthritis, gout, or other disorders of muscle, joints, spine, stomach, intestines, chest pain, or asthma? Yes No

d) Within the last 12 months, had any kind of medication prescribed? Yes No

e) Within the last 5 years, suffered from any disease, or received medical or surgical treatment for any conditions not listed in question 11? Yes No

12) Has the proposed insured or additional insured been treated for any previous or existing medical conditions? Yes No
  Family Member:
  Condition Details:
  Age if Living:
  Age at Death:
Comments: