1. Clients name and date of birth? Male or Female?
2. Tobacco user? If yes, type of usage (cigars, pipe, chew, cigarettes, nicotine gum, nicotine patches). If stopped, date tobacco use was stopped.
3. Has any immediate relative (father, mother, sister, brother) had an occurrence of or died prior to age 60 of, heard disease, diabetes complications, or cancer?
4. Any treatment for elevated blood pressure? BP readings and cholesterol?
5. Any conditions related to the heart? Angioplasties, bypass, etc.
6. Any cancer or surgery in the past 20 years?
7. Height and weight?
8. Any history of diabetes?
9. Name all medications currently being taken. Include dosage and frequency (i.e. 25mg., 2X per day).
10. Any history of drug or alcohol abuse"
11. More than 2 moving violations in 3 years, DUI, or suspension in the past 5 years?
12. Ever convicted of a felony?
13. U.S. Citizen, permanent resident, or green card holder?
14. Do you fly an airplane or participate in any other hazardous activities (scuba diving, sky diving, racing)?
15. Any other medical impairment or other underwriting problems (what & when)?
16. What are the product, face value amount, and premium range desired?
17. Prior company action (name of company, rating, premium)?