| Life Questionnaire |
| The following fields must be filled out completely and accurately
in order to obtain a quote. |
|
| Personal
Information |
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| Insured's
Name: |
|
| Address: |
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| City: |
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| State: |
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| Zip: |
|
| Phone: |
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| E-mail: |
|
|
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| Best Time to Contact
You: |
Daytime Evening |
| Best Place to Contact
You: |
Work Home |
| Sex: |
Male
Female |
Date of
Birth:
Month/Day/Year |
/ / |
| Your
Height: |
Feet
Inches |
| Your
Weight: |
Pounds |
|
|
| How much life insurance would
you like us to quote? |
|
| What type of life insurance are
you looking for? |
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| Description of other type of
coverage you are looking for: |
|
| The coverage to be quoted will
likely be: |
|
| Tobacco
Usage: |
Month and Year Quit:
|
| Do you take any prescription
medication? |
Yes No |
| If yes please
explain: |
|
| Do you have any health
problems? |
Yes No |
| If yes please
explain: |
|
| Are you a private
pilot? |
Yes No |
| If yes, please explain type of
rating, type of aircraft, total number of hours experience, and hours
flown per year: |
|
| Do you engage in scuba diving,
sky diving, rock climbing, motorized racing, or other hazardous avocation
or occupation? |
Yes No |
| If yes, please explain in
detail: |
|
| Have you been convicted of
drunk driving, or had your driver's license suspended or revoked in the
past five years? |
Yes No |
| If yes, please explain in
detail: |
|
| Have you been convicted of
three or more moving violations in the past three
years? |
Yes
No
|
| Have you ever been convicted of
a felony? |
Yes
No |
| If yes, please explain dates,
charges, and details: |
|
| In the past 10 years, I have
been advised regarding, or been treated for: |
Hypertension Heart Disease Cancer Diabetes
Stroke Alcohol or Drugs AIDS Other |
| If you checked any of the
above, please explain: |
|
| Did any of your grandparents,
parents or siblings have heart disease or cancer, prior to age
65? |
Yes No |
| If yes, please
explain: |
|
| Any other Questions or
Comments? |
|
