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Applicant Information |
* Applicant's Name: |
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* Date Of Birth: |
00/00/0000 |
* Gender: |
Male
Female |
* Height: |
ft/in |
* Weight: |
lbs |
* Occupation: |
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* Death Benefit: |
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* Type of Product: |
Term
Universal
Whole Life
Second to Die
Variable |
Tobacco Use: |
Yes
No
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Replacement? |
Yes
No
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Current Annum Premium |
$
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Last Life Ins. Application |
Year
Company
Action |
Occupation: |
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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): |
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Driving Record:
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Number of violations in past 3 years?
# of DUI / Reckless Driving in past 5 years?
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Do you exercise 3 or more times per week? If yes, please give details: |
Yes
No
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Date of last medical checkup: |
00/00/0000 |
Date of last EKG: |
00/00/0000
Results: |
Last blood pressure reading: (results)
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00/00/0000 |
Are you treated for blood pressure? |
Yes
No
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Last Cholesterol Reading, HDL reading (results): |
00/00/0000 |
Are you treated for cholesterol? |
Yes
No
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1. Have you ever had seizures or fainting spells? (Indicate type (Petit Mal, Grand Mal, etc.) and dates: |
Yes
No
If yes, please explain and give dates:
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2. What did your doctor tell you was the reason or cause (e.g. epilepsy, tetany)? |
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3. How often do you have attacks?
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Weekly
Monthly
Yearly
On what occasions?
During the:
Day or
Night
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4. How long do the attacks usually last?
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5. When was the last attack? |
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6. What kind of treatment have you received (medical and/or surgical)? Give full particulars and dates. |
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7. Do you have any other diseases, symptoms or complaints? |
Yes
No
If so, please give full particulars:
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8. Do you receive or have you ever received any kind of disability compensation? |
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9. Name and address of your attending physician. |
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| Please fill out all information completely and accurately. |
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