Contact Information

• Name:
• Address:
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• Home Phone Number:
• Work Phone Number:
• Fax Number:
• Your Email Address:

Quote Information

Date of Birth:	mm/dd/yyyy
Gender:	Male Female
Have you used tobacco?:	No Yes If 'Yes', specify type, date of last use Type: Date: mm/yyyy Cigarette Cigar Pipe Chewing Tobacco
Height & Weight:	(ex: 5' 8") (ex: 150 lbs)
Are you a private pilot?:	No Yes If ' Yes' complete Aviation Section in the Additional Categories list below.
Amount Needed:	$ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000 $ 60,000 $ 70,000 $ 80,000 $ 90,000 $ 100,000 $ 125,000 $ 150,000 $ 175,000 $ 200,000 $ 225,000 $ 250,000 $ 275,000 $ 300,000 $ 325,000 $ 350,000 $ 375,000 $ 400,000 $ 425,000 $ 450,000 $ 475,000 $ 500,000 $ 550,000 $ 600,000 $ 650,000 $ 700,000 $ 750,000 $ 800,000 $ 850,000 $ 900,000 $ 950,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000
Policy Type:	Term Permanent Second-to-Die
Desired Premium Range:

General Medical

Describe your Health / Medical impairment or Special risk:
Date Diagnosed:
Medications (Include Dosage):
Cholesterol:	Ratio:
Blood Pressure:
Types and dates of surgery or hospital treatments:
Family History ("Father", "Mother", "Siblings") Give Reasons for any Deaths prior to age 60:
Since diagnosis, list any lifestyle changes: (Exercise Program, Stopped Smoking, etc.):

Select and complete the additional categories that apply then
SUBMIT REQUEST for processing. If none of the categories below apply to your situation then click SUBMIT REQUEST now.
Alcoholism / Drug Abuse	Aviation	Build
Cancer	Cardiovascular Impairments	Chronic Pulmonary ( Lung ) Disease
Depression/Anxiety Disorder	Diabetes	Elevated Liver / Enzymes
Financial Justification	Hazardous Activities	Hypertension
Moral Hazard	Sleep Apnea

Alcoholism / Drug Abuse

Alcohol:
How long since you last consumed alcohol?:
Are you a member of AA or a similar organization? (Give Details; Dates, How Often do you Attend Meetings):
Current Family Situation:
Current Occupational Situation:
Has blood profile (including liver function tests, and "Alcohol Marker") been performed by a Physician within last 12 months?:	No Yes If 'Yes' Describe Results:
Drug Abuse:
Name of Drug Used:
Date of Last Use:
Current Family Situation:
Current Occupational Situation:
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Aviation

Total flight hours logged:
Make of aircraft flown:
Type of certification:
Year issued:
Do you have an instrument flight rating (IFR)?:	No Yes
Hours flown in the last 12 months:
Estimated hours for the next 12 months:
Personal use:	%
Business use:	%
Type of business use:
Military Info:
Do you fly military aircraft?:	No Yes If 'Yes' Type of Aircraft:
Estimated hours per year:
Purpose and frequency of military travel:
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Build

Highest weight ever:
Highest weight in the last 10 years:
Approximate weight of immediate family members (mother, father, siblings):
Has an immediate relative (Mother, Father, Siblings) died prior to age 60 of Heart Disease, Diabetes, or Cancer?:	No Yes If 'yes' explain:
Amount of weight loss (if any) in the last 12 months:
Have you had an EKG or any other Cardiac related testing performed in the last 5 years?:	No Yes If ' yes', type of test performed, and when: Where there any noted abnormalities? No Yes If 'yes', explain:
What efforts are being made to control your weight? (exercise, diet, meds, etc...):
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Cancer

Date cancer diagnosed:
Type (e.g. adenocarcinoma, melanoma, ect...):
Location (e.g. prostate, liver ect...):
Stage, Grade or Clark's level:
Any Chemotherapy or Radiation treatment?	No Yes If 'yes', date of last treatment and total number of treatments:
Any Other Treatments?	No Yes If 'yes', provide detail:
Any Mestastasis? (spreading to other parts of the body)	No Yes If 'yes', provide detail:
Any Lymph Node Involvement?	No Yes If 'yes', provide detail:
Any Recurrences or Relapses?	No Yes If 'yes', date of last treatment and total number of treatments:
Any Family History of Cancer?	No Yes If 'yes', date of last treatment and total number of treatments:
If Prostate Cancer, Provide Results and Dates of Most Recent PSA Readings:
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Cardiovascular Impairments

Date of diagnosis:
Type of impairment (Heart Attack, Bypass, Angioplasty, Heart Murmur, etc...):
Type of surgery or treatment (if Bypass, # of vessels involved):
Is there any history of chest pain? (include dates):
Current medications? (include dosages):
What tests were performed? (Treadmill, EKG, Echocardiogram, etc...):
What were the results?:
Please give details regarding: 1)blood pressure 2) cholesterol 3) build 4) family history 5) diabetes:
Describe any lifestyle changes made since the Cardiac event: (exercise, diet, etc...)
Family History (Give "Reasons" for any deaths prior to age 65: include father, mother, siblings):
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Chronic Pulmonary (Lung) Disease

Type of lung disease: (Asthma, Emphysema, COPD, etc...):
Date of diagnosis::
Have you ever been hospitalized for this condition (details):	No Yes If ' Yes', explain:
List current medications:
Has a Pulmonary function test been performed?:	No Yes Dates and results of PFT test:
Has a chest X-ray been performed?:	No Yes If ' Yes', explain:
Do you have any restrictions on day-to-day activities?:	No Yes If ' Yes', give details:
How is the impairment treated? (medication, breathing machine, etc...):
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Depression/Anxiety Disorder

Diagnosis:
Date of diagnosis:
Type of treatment:
Date of last treatment:
Current medication(s):
Any other medical history:
Any suicidal attempts/thoughts?:	No Yes If 'Yes', how often:
Date of last incident:
Duration that you have been under effective control:
Current family/occupational situation:
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Diabetes

Date of diagnosis:
Age at diagnosis:
Type and amount of medication/diet:
Any problems with your eyes, circulation, diabetic coma, protein in urine, etc...?:	No Yes If ' Yes', date and nature of problem/treatment and outcome:
Do you check your blood / urine on a regular basis?:	No Yes If 'Yes', how often?: If ' Yes', what are the results?:
Date and result of last fasting Glucose test:
Do you see a doctor regularly?:	No Yes If 'Yes', what are the results of the doctor's blood work:
Date and result of last Hemoglobin "A1C" test:
Have you had an EKG performed in the last 5 years?:	No Yes If 'Yes', where there any abnormalities detected?: No Yes If 'Yes', explain:
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Elevated Liver Functions/Enzymes

Date of last blood test:
Results of GGTP (normal 2-65):
Results of SGOT (normal 2-45):
Results of SGPT (normal 2-50):
Have these results been increasing, decreasing, stable or fluctuating?:
Do you currently drink alcohol?:	No Yes If ' Yes', frequency and quantity of use:
Have you been diagnosed or tested for Hepatitis?:	No Yes If ' Yes', describe results (+ or -):
Have you ever had a Liver Biopsy performed?:	No Yes (Answer only, in severe cases of Liver Enzyme elevations, or if there is a history of Hepatitis ) If 'Yes', give date and describe results:
Are you currently taking any medications?:	No Yes If 'Yes', give details:
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Financial Justification

Amount of business insurance on other individuals:
If insurance is for business purposes, what is the percentage of proposed insured ownership?:	%
Explain details of the sale, and any special circumstances of the case:
Are you replacing another policy?:	No Yes If 'Yes', present carrier: If ' Yes', include a 5-year replacement history on the case:
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Hazardous Activities

Skin/Scuba Diving:
How deep do you dive?:
Number of dives in the last 12 months:
Number of expected dives in the next 12 months
List all your certifications:
Where do you dive? (include oceans, lakes, etc.):
Sky Diving:
Jump altitude?:
Number of jumps in the last 12 months:
Number of expected jumps in the next 12 months
List and describe any certifications:
Racing Cars, Boats, and Motorcycles:
Type of vehicle and top speed:
If racing, what type of event?:
If racing, what type of fuel is used?:
Classification of vehicle and type of track:
If race is sanctioned by an association please explain:
Other:
Type of activity:
How often do you participate in this activity?:
How long have you participated in this activity?:
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Hypertension

Please give previous high readings and dates of readings:
Current blood pressure reading:
Current medications and how long you've been taking them.:
Have you ever experienced chest pains?:	No Yes If ' Yes', date of first occurrence: If ' Yes', date of last occurrence:
Have you had an EKG or any other Cardiac related testing performed in the last 5 years?:	No Yes If ' Yes', type of test(s) performed and when?: Where there any noted abnormalities? No Yes If ' Yes', explain:
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Moral Hazard

Type of problem (ie; criminal record, lack of applicant candor, criminal associates, convictions, etc...):
Date(s) associated with incidences:	Date of last occurrence:
Have you ever been convicted?:	No Yes If ' Yes', has time been served, or is case in appeal (explain)?:
Are you currently on parole?:	No Yes If ' Yes', when will parole be lifted?:
Describe any lifestyle changes (stable employment, etc.):
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Sleep Apnea

Date of diagnosis:
How is the condition being treated? (CPAP, Mask, Weight Loss, Surgery, etc...):
Please note the date of the most recent sleep study?:	What were the results of the study?:
Has the condition been diagnosed as mild, moderate, or severe?:	Mild Moderate Severe
What were the original "symptoms" that led to the diagnosis?: (Snoring, lack of sleep, etc...)
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