Name

Address

City State Zip

Death Benefit Amount

Product:     Term  10-Year 15-Year 20-Year 25-Year 30-Year      Term For Life     Universal Life

D.O.B.     Height 4'9" 4'11" 4'10" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11" 7'0"     Weight

1. Have you ever had any major surgeries or major health complications (such as Cancer, Heart Disease, Diabetes, Asthma, Sleep Apnea or Rheumatoid Arthritis)? No Yes

If yes, what condition(s)?

When was it diagnosed?

2.  Are you taking any prescribed medications? No Yes

If yes, list medication(s):
 

3.  Have you EVER or do you PRESENTLY use any tobacco products? No Yes

If yes check any that apply: CigarettesCigarsPipeChew/Dip

How Often?        Last Used? Currently Within the Year 1-2 Years 3-5 Years Over 5 Years

4.  Are your parents still living? Yes No

            Age if Living    Cause of Death    Age at Death

Mom                              

Dad                                

5.  Have you ever been charged a higher premium or been declined for life insurance?  No Yes

If yes, why?

6.  Do you participate in any hazardous activities such as piloting, scuba, bungee, or rock climbing? No Yes

If yes, list what activities:
 

How often?

7.  Is there anything else in your personal history you feel may be relevant in your qualifying for a life insurance policy? No Yes

 If so, please explain:

8.  Is there any family history (parent or sibling) of Diabetes, Cancer, High Blood Pressure, Heart or Kidney Disease, Alcoholism, Mental Illness, or Suicide?  No Yes

If yes, please provide details:

Any Additional Comments: