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
|
1. Please give date of diagnosis: |
00/00/0000 |
2. Please note type diagnosed:
|
Obstructive
Central
Mixed |
3. Has a sleep study, or studies been completed? |
|
4. What treatment has been prescribed (please check all that apply): |
Observation Alone
Weight Loss Alone
CPAP Mask (Continuous positive airway pressure)
If checked, Date last used:
Surgery (Tracheotomy or Uvulopalatopharyngoplasty)
Medication, please detail type and dosage:
|
5. Are there any current symptoms? |
Yes
No
If yes, please detail
|
6. Has the client experienced any of the following illnesses (check all that apply and give details): |
Arrhythmia
Type:
Other heart related conditions
Type:
Asthma, COPD, or Emphysema
Type:
Depression
Overweight, please confirm height and weight
Height:
Weight
|
7. Has the client smoked cigarettes in the past 12 months? |
Yes
No
Please detail amount per day and date stopped if no longer smoking:
|
8. 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. |
|
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