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General Health Questionnaire
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Agent Name:
*
First
Last
Agent's Phone Number:
*
Agent's Email:
*
State of Issue/Delivery:
*
Alabama
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Proposed Insured's Name:
*
First
Last
Sex:
*
Male
Female
What is the proposed insured's:
*
Date of Birth
Age
Please select "age" if the date of birth is unknown.
Date of Birth:
*
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Age:
*
Height:
*
Weight:
*
Ever a marijuana/THC user?
Yes
No
Current marijuana/THC user?
*
Yes
No
How is/was the marijuana or THC consumed?
*
Smoked
Drops
Pills
Vape
Other
Please describe:
*
Quantity used per occasion:
*
How often do/did you use marijuana or THC?
*
Ever a cigarette smoker?
*
Yes
No
Current cigarette smoker?
*
Yes
No
Date last used:
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Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.)
*
Yes
No
Please provide details for any other tobacco use:
Last date any form of tobacco was used:
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Is this case being premium financed?
*
Yes
No
Do you have a lender?
*
Yes
No
Insurance Type:
*
Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product
Face Amount:
*
Are there multiple policies/face amounts?
Yes
No
Face Amount:
Are you requesting any riders?
Yes
No
Type of rider:
Waiver of premium
Child term rider
LTC/CI type rider
Other
Please specify:
**Our underwriters may need additional information in order to provide quote.
Have you ever been treated for, or diagnosed with: (If “yes,” please provide details under each question.)
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 specify:
High blood pressure
Heart attack
Chest pain
Heart murmur
Irregular heartbeat
Stroke
Any other disease or disorder of the heart or blood vessels
Any other disease or disorder of the heart or blood vessels - Please describe:
Date of diagnosis:
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Please provide details:
Cancer or a tumor, cyst or growth?
Yes
No
Please specify:
Cancer
Tumor
Cyst
Growth
For further quoting, please complete the current questionnaire. After submission, you will receive a link to our cancer questionnaires.
Date of diagnosis:
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Type:
Stage and/or Grade:
Treatment given:
Has there been any recurrence?
Yes
No
Please provide details:
Asthma, bronchitis, emphysema, sleep apnea, tuberculosis or any other disease or disorder of the lungs or respiratory system?
Yes
No
Date of diagnosis:
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Please provide details including any treatment:
Seizure, paralysis, headaches, multiple sclerosis or any other disease or disorder of the brain or nervous system?
Yes
No
Please specify:
Seizure
Paralysis
Headaches
Multiple Sclerosis
Any other disease or disorder of the brain or nervous system
Date of diagnosis:
MM
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Please provide details including any treatment:
Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder?
Yes
No
Date of diagnosis:
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Please provide details including any treatment:
Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract?
Yes
No
Please specify:
Hepatitis
Colitis
Ulcer
Cirrhosis
Irritable bowel
Any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract
For further quoting, please complete the current questionnaire. After submission, you will receive a link to our hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract questionnaires.
Any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract - Please describe:
Date of diagnosis:
MM
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Has the proposed insured received any treatment for the above disease or disorder?
Yes
No
Please specify treatment:
Please provide information on medications currently taking:
Please list the following information: Name of Medication (Prescription or Otherwise), Dates Used, Quantity Taken, and Frequency Taken
Please provide any additional details:
Diabetes, borderline diabetes, sugar in the urine, thyroid disorder, or any other disease or disorder of the glandular system?
Yes
No
Please specify:
Diabetes
Borderline diabetes
Sugar in the urine
Thyroid disorder
Any other disease or disorder of the glandular system
Type of diabetes:
Date of diabetes diagnosis:
MM
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Current A1C test reading:
Date of most current A1C test reading:
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1933
1932
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Please specify - Any other disease or disorder of the glandular system
Please provide details including any treatment:
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
Date of diagnosis:
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Has the proposed insured received any treatment for the above disease or disorder?
Yes
No
Please specify treatment:
Please provide any additional details:
Any disease or disorder of the bones, joints, or muscles?
Yes
No
Date of diagnosis:
MM
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1920
Has the proposed insured received any treatment for the above disease or disorder?
Yes
No
Please specify treatment:
Please provide any additional details:
Have your parents or siblings died as a result of cancer, stroke, or heart disease prior to age 60?
Parents
Siblings
Select all that apply
Parent's age when diagnosed:
Sibling's age when diagnosed:
Are you currently or have you taken any medications (prescription or otherwise) within the last two years?
Yes
No
Please provide name of medication and dosage:
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 last 5 years…
Have you engaged in any of the following activities: aviation, scuba/skin diving, organized motor vehicle racing (i.e. snowmobile or motorboat), skydiving, hang gliding, mountain climbing, or rodeo?
Yes
No
Please specify:
Aviation
Scuba/skin diving
Organized motor vehicle racing (i.e. snowmobile or motorboat)
Skydiving
Hang gliding
Mountain climbing
Rodeo
For further quoting, please complete the current questionnaire. After submission, you will receive a link to our aviation questionnaires. Please note: All aviation activity is summitted to our carriers for review.
Please provide details:
Have you traveled outside the U.S. or Canada?
Yes
No
Please provide details:
Any future plans to travel abroad?
Yes
No
Please provide details:
Have you been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations?
Yes
No
Please provide date(s):
Please provide details:
Have you been on parole or probation or convicted of a felony or misdemeanor?
Yes
No
Please provide details including date(s) parole/probation was lifted:
Have you regularly used, or are you currently using any controlled substance, excluding marijuana?
Yes
No
Please provide details:
Have you ever been medically advised to limit or discontinue the use of alcohol or drugs, or sought or received treatment?
Yes
No
Please provide details:
Do you exercise regularly?
Yes
No
Please provide details:
Please provide additional details about the proposed insured’s medical history:
Submit