Applicant Information |
* Applicant's Name: |
|
* Date Of Birth: |
00/00/0000 |
* Gender: |
Male
Female
|
* Height: |
ft./in |
* Weight: |
lbs. |
* Occupation: |
|
* Death Benefit: |
|
* Type of Product: |
Term
Universal
Whole Life
Second to Die
Variable
|
Tobacco Use: |
Yes
No
|
Replacement? |
Yes
No
|
Current Annum Premium |
$
|
Last Life Ins. Application |
Year
Company
Action |
Occupation: |
|
Marital Status: |
Single
Married
Widow
Divorced |
Family History: (age if still living) |
Father
Mother
Sibling 1
Sibling 2
Sibling 3 |
If any deceased, give relation(s), age(s), and cause(s): |
|
Driving Record:
|
Number of violations in past 3 years?
# of DUI / Reckless Driving in past 5 years?
|
Do you exercise 3 or more times per week? If yes, please give details: |
Yes
No
|
Date of last medical checkup: |
00/00/0000 |
Date of last EKG: |
00/00/0000
Results:
|
Last blood pressure reading: (results)
|
|
Are you treated for blood pressure? |
Yes
No
|
Last Cholesterol Reading, HDL reading (results): |
|
Are you treated for cholesterol? |
Yes
No
|
Detail the client's medical history (Check all that apply):
Cancer History
Heart History/Condition
Diabetes History
Alcohol or Drug Abuse History
High blood pressure, Please detail:
|
Current reading
Highest reading and date
|
Type of Treatment:
|
Elevated Cholesterol history, please detail: |
|
EGK if taken within past year |
Results:
Normal
Other
Explain:
|
Stress EKG or Thallium, if taken within past year: |
Results:
Normal
Other
Explain:
|
Sigmoidoscopy, if taken within past year: |
Results:
Normal
Other
Explain:
|
Prostate exam, if taken within past year: |
Results:
Normal
Other
Explain:
|
Mammogram, if taken within past year: |
Results:
Normal
Other
Explain:
|
Height:
Weight
Weight lost in last year:
|
Last measured body fat %
Date
00/00/0000 |
Men Only: |
Chest:
Inches
Waist :
Inches |
Has client had a standard medical check up within the past year?
If yes, please detail results:
|
Yes
No
Results:
Normal
Other
Explain:
|
List any other illnesses or impairments, along with all meds and vitamins taken, include dosage and frequency: |
|
| Please fill out all information completely and accurately. |
|
|
