RIA General Health Questionnaire

General Health Questionnaire

Please complete this form to aid in the preparation of your insurance quote. Completion of this form does not constitute completion and/or submission of an application for insurance.

If you have questions, please email insurance@dbs-lifemark.com or call:

Jim Boldischar: 877.593.7655

All completed forms are submitted via our secure server so you can be assured that your information is safe with us.

Applicant Information
Name of Advisor you are working with:
First Last
Applicant's Name*
First Middle Initial Last
Social Security Number*
Email*
Residence Phone*
Cell Phone*
Relationship Status*
Address*
Street Address Address Line 2 City State ZIP Code
Gender:*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
Height*
ft. in.
Weight*
lbs.
Driver's License*
Number State Exp. Date
Occupation*
Employer*
Net Worth*
Annual Income*
Do you have any existing life insurance policy(ies) or annuity contract(s)?*
- Yes
- No
Policy #1*
Carrier Policy # Amount Year Issued
Beneficiary
Replacement
- Yes
- No
Policy #2
Carrier Policy # Amount Year Issued
Beneficiary
Replacement
- Yes
- No
Policy #3
Carrier Policy # Amount Year Issued
Beneficiary
Replacement
- Yes
- No
Current cigarette smoker?*
- Yes
- No
Ever a cigarette smoker?*
- Yes
- No
Date of last cigarette use:*
MM slash DD slash YYYY
Any other tobacco use?*
- Yes
- No
Cigar, pipe, snuff/chew, patch, gum, e-cigarette, vape
Details regarding other tobacco use:*
Date of last use (other form)*
MM slash DD slash YYYY
Have you had a complete exam within the past 2 years?*
- Yes
- No
Please indicate the date and any significant findings.
Doctor's Name
First Last
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Have you ever been declined or rated for life insurance?*
- Yes
- No
Please provide details.
In the last 10 years, have you been treated for, or diagnosed with:
High blood pressure, heart attack, chest pain, heart murmur, irregular heartbeat, stroke, or any other disease or disorder of the heart or blood vessels?*
- Yes
- No
Please provide details in the space below.
Cancer or a tumor, cyst, or growth?*
- Yes
- No
Type of cancer:
Stage and/or grade:
Please provide additional details.
Asthma, bronchitis, emphysema, tuberculosis, or any other disease or disorder of the lungs or respiratory system?*
- Yes
- No
Please provide details in the space below.
Seizure, paralysis, headaches, multiple sclerosis or any other disease or disorder of the brain or nervous system?*
- Yes
- No
Please provide details in the space below.
Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder?*
- Yes
- No
Please provide details in the space below.
Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract?*
- Yes
- No
Please provide details in the space below.
Diabetes, borderline diabetes, sugar in the urine, thyroid disorder, or any other disease or disorder of the glandular system?*
- Yes
- No
Please provide details in the space below.
Kidney stones, nephritis, any blood or protein in the urine, sexually transmitted disease, prostate disorder, breast disorder or any other disease or disorder of the urinary or reproductive system?*
- Yes
- No
Please provide details in the space below.
Any disease or disorder of the bones, joints, or muscles?*
- Yes
- No
Please provide details in the space below.
Any family history (parents or siblings) of diabetes, cancer, stroke, or heart disease?*
- Yes
- No
Please give details: please indicate if living or deceased, age at death and cause of death. Give age when diagnosed and how treated, etc.
Are you currently or have you taken any medications within the last two years?*
- Yes
- No
Please list medications currently taking, including dosage and frequency.
Have you had any surgeries in the last 6 months or are there plans for surgery in the near future?*
- Yes
- No
Please provide details in the space below.
In the past 5 years, have you engaged in any of the following (check all that apply):*
- Private pilot, scuba/skin diving, organized motor vehicle racing (i.e. snowmobile or motorboat), skydiving, hang gliding, mountain climbing, or rodeo?
- Traveled outside the U.S. or Canada? Any future plans to travel abroad?
- Been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations?
- Been on parole or probation or convicted of a felony or misdemeanor?
- Regularly used or are you currently using marijuana or other controlled substances?
- Ever been medically advised to limit or discontinue the use of alcohol or drugs, or sought or received treatment?
- None of the above
Please provide details to any "yes" answers in the space below.
Do you exercise regularly?
- Yes
- No
Please provide any additional details about your health history:

General Health Questionnaire

Applicant Information

In the last 10 years, have you been treated for, or diagnosed with: