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. Type of lung disease: |
Chronic Bronchitius
Emphysema
Restrictive Lung Disease
Asthma |
2. Please list date when first diagnosed: |
00/00/0000 |
3. Has the client ever been to hospitalized for this condition? |
Yes
No
If yes, please give date:
|
4. Has the client ever smoked?
|
Yes, currently smokes
(amount/day)
Yes, smoked in the past but quit
date
No, never smoked
|
5. Is your client on any medication, an inhaler, or oxygen tank for the disease? |
Yes
No
Please detail:
|
6. Has the client had a recent pumonary function (breathing test)? |
Yes
No
Please give results:
|
7. Does the client have any abnormalities on an ACG or X-Ray? |
Yes
No
Please detail:
|
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. |
|
|
