* Required Information

Applicant Information
* Applicant's Name:
* Date Of Birth:	00/00/0000
* Gender:	Male Female
* Height:	ft/in
* Weight:	lbs
* Occupation:
* Death Benefit:	Choose Value 50,000 100,000 150,000 200,000 250,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000 7,500,000 10,000,000
* 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)	00/00/0000
Are you treated for blood pressure?	Yes No
Last Cholesterol Reading, HDL reading (results):	00/00/0000
Are you treated for cholesterol?	Yes No
1. List dates of heart attacks and severity of each:	Mild Moderate Severe month/year Time until return to normal activities ________________________________________________ Mild Moderate Severe month/year Time until return to normal activities
2. What condition(s) preceded the heart attack(s)?	Chest Pain Arrhythmia or Irregular heart beats Irregular EKG Irregular Stress EKG Other Explain
3. Does client work full time?	Yes No
4. Activities capable of performing? (Check level of exercise that best applies):	Level One -heavy labor, handball, cross country skiing, running 10 minute miles, bicycling at 12 mph Level Two - shoveling, wood cutting, canoeing, jogging 12 minute miles, swimming crawl stroke, rowing machine Level Three - carpentry, lawn mowing, singles tennis, downhill skiing, swimming breast stroke Level Four - Sedentary lifestyle (unable to do any of levels one through three)
5. Since the heart attack, has the client experienced any of the following?	Chest Pain or Angina Irregular EKG or Stress EKG Arrhythmia Congestive Heart Failure
6. What treatment(s) have been prescribed?	00/00/0000 Date last consulted Physician List all medications: Angioplasty or bypass (use the additional QQ form) Other treatments, please describe
7. What tests have been performed? (Check all that apply):	Resting EKG Date Results Exercise EKG Date Results Thallium Test Date Results Stress Echo Date Results Coronary Catheterization Date Results
8. List any other illnesses or impairments (complete any other quick quote forms that may apply) along with all meds and vitamins taken, include dosage and frequency:
Please fill out all information completely and accurately.