Health
What is your date of birth?
Have you used any tobacco, nicotine or marijuana products in the last 5 years?
*
Yes
No
Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema or Asthma?
*
Yes
No
Do you require the use of any oxygen or inhalers?
*
Yes
No
Have you ever been diagnosed or received treatment for diabetes?
*
Yes
No
Have you ever been diagnosed with Cancer?
*
Yes
No
Have you ever had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism?
*
Yes
No
Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s?
*
Yes
No
Congestive Heart Failure?
*
Yes
No
Have you ever been diagnosed or received treatment for Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s or Dementia?
*
Yes
No
Are you taking any medications?
*
Yes
No
Medications
Medicine Name
Dosage
Years Taken (ballpark is fine)
Used for
Financials
Do you have any active burial or life insurance inforce?
*
Yes
No
Do you have an active checking or savings account?
*
Yes
No
Is anyone other than you paying for this policy?
*
Yes
No