Pre-Qualification Questionnaire - Life

Please fill out the form as completely as possible. We may not be able to provide a quote if the form is not complete.

Applicant Name:

Date of Birth: (e.g. 2/14/1960)       Sex:    


Height: ft. in.       Weight: lbs.

1. Have you ever used any form of tobacco (Cigarettes, pipes, cigars, chew & nicotine gum)?
   
If yes: type, quantity, number of years used & last used (MM/DD/YEAR):


2. Have you ever been rated or declined for insurance?
   
If yes, date, reason and name of company:


3. Have you ever been treated for high blood pressure or cholesterol?
   
If yes, date diagnosed and last reading:


4. Are you currently taking any prescription medications?
   
If yes, prescription name and current dosage:


5. Has any member of your immediate family (parent or sibling) been treated for coronary artery disease or cancer?
   
If yes, list Relationship, Diagnosis, Age at Diagnosis, Age Deceased (if applicable):


6. In the past three years have you had three or more moving violations or had your driver's license suspended or revoked or been convicted of a DUI?
   
If yes, type of violation, conviction date, treatment recommended:


7. Have you ever been told by a physician, psychiatrist, psychologist or other medical practitioner you had, or been treated for:
   A. Diabetes, Fainting, seizure, alcoholism or depression?
   B. Cardiovascular, respiratory, digestive, liver, kidney, or blood disease or disorder?
   
If yes:
Diagnosis     Date     Treatment/Medication     Duration     Current Status


Requested by:

Requestor E-mail: (to receive confirmation)

Requestor Fax:

Death Benefit: $

Term:                    





Comments: