General Health Questionnaire

Agent Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

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.

Height: *

Weight: *

Ever a marijuana/THC user?

Ever a cigarette smoker? *

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Is this case being premium financed? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Are you requesting any riders?

**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?

Cancer or a tumor, cyst or growth?

Asthma, bronchitis, emphysema, sleep apnea, tuberculosis or any other disease or disorder of the lungs or respiratory system?

Seizure, paralysis, headaches, multiple sclerosis or any other disease or disorder of the brain or nervous system?

Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder?

Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract?

Diabetes, borderline diabetes, sugar in the urine, thyroid disorder, or any other disease or disorder of the glandular system?

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?

Any disease or disorder of the bones, joints, or muscles?

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

Are you currently or have you taken any medications (prescription or otherwise) within the last two years?

Have you had any surgeries in the last 6 months or are there plans for surgery in the near future?

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?

Have you traveled outside the U.S. or Canada?

Have you been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations?

Have you been on parole or probation or convicted of a felony or misdemeanor?

Have you regularly used, or are you currently using any controlled substance, excluding marijuana?

Have you ever been medically advised to limit or discontinue the use of alcohol or drugs, or sought or received treatment?

Do you exercise regularly?

Please provide additional details about the proposed insured’s medical history:

Save and Resume Later

**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.)

For further quoting, please complete the current questionnaire. After submission, you will receive a link to our cancer questionnaires.

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.

In the last 5 years…

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.