Life Insurance Questionnaire

Name*:

Mailing Address:

Email*:

Phone*:
 

Do you smoke cigarettes or any other form of tobacco
products?

Yes No

If you quit smoking how long has it been? (be honest...)

Years   Months 

Number of alcoholic beverages per week?

Are you now taking any prescription medications?

Yes  No

If yes, please list: (with diagnosis, name and dosage)

Have you had a major change in your health in the past 
7 years?
If yes, please explain:

Have you been in the hospital in the past 7 years?
If yes, please explain:

Have you had a DUI in the past 5 years?

Yes  No

Did your Mother or Father die from cancer or heart disease prior to age 60?

Yes  No

Please list your hobbies:

Do you exercise regularly?

Yes  No

Do you believe your lab work (blood & specimen) are normal?

Yes  No

Height

Weight

Age

* Indicates required field