| 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)
|
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. What caused the paralysis? |
Trauma
Give details and date of occurrence
Surgery
Give details including reason for surgery and date of occurrence
Stroke or cerebral vascular accident
Other, please give details
|
2. Please note current level of function: |
Incomplete Paraplegia
Complete Paraplegia
Incomplete Quadriplegia
Complete Quadriplegia
|
3. If paralysis from injury or trauma, at what spinal cord level (list specific vertebrae if possible, C-7-8, for example) |
Cervical Spine
Thoracic Spine
Lumbrosacral Spine
|
4. Have any of the following occurred (check all that apply):
|
Pneumonia
Skin Ulcers
Urinary Tract Infection
Kidney Impairment
Depression |
5. Are there any current symptoms or complications (check all that apply): |
|
6. Is treatment currently being prescribed? |
Yes
No
Please detail:
|
7. 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. |
|
|
