Date: ________________
Spoke to: ________________________
Questions for Personalized Price Quotation
(Questions must be asked exactly as written here)
- Proposed Insured ______________________________________________ Date of birth? ___________________
- What is your EXACT Height and Weight? Height_____________Weight_________________
- Have you used ANY FORM of tobacco/nicotine in the last 5 years? Yes ? No ? Currently Using? Yes ? No ?
- Quit/Date:_______ Type: Cigarettes ? Cigars ? Chew ? Nicotine Gum ? Quantity ________________
- Are you taking ANY prescription medications? If YES, need details of medications and why are you taking them.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________ - Have you ever had HBP? What was your last Blood Pressure reading?
_________________________________________________________________________________________________ - Have you ever been told you have high cholesterol? Do you know your cholesterol numbers? Total Cholesterol?
Cholesterol/HDL Ratio?
_________________________________________________________________________________________________ - Did you have ANY Natural Parents or Brothers and Sisters that were diagnosed with or died from HEART
PROBLEMS, STROKES, DIABETES OR CANCER, PRIOR TO AGE 60?
If Yes, ___________________________________________________________________________________________
_________________________________________________________________________________________________ - Have you EVER had ANY past health concerns such as HEART, STROKE, DIABETES, CANCER,
RESPIRATORY, CIRCULATORY, ANXIETY/DEPRESSION, SLEEP APNEIA, or any other internal problems? If
YES, see additional specific questions below relating to any of the
above____________________________________________________________________________________________
_________________________________________________________________________________________________ - Have you EVER had ANY DRUG OR ALCOHOL problems or received any treatment for either in the past?
_________________________________________________________________________________________________ - Have you had 2 or more moving violations in the past 2 years or ANY DUI’s, DWI’s, or RECKLESS or CARELESS
Driving convictions in the last 10 years?
_________________________________________________________________________________________________ - Do you participate in ANY HAZARDOUS SPORTS OR HOBBIES such as PRIVATE PILOTING, SCUBA DIVING,
MOUNTAIN CLIMBING OR ANYTHING CONSIDERED HAZARDOUS?
_________________________________________________________________________________________________
_________________________________________________________________________________________________ - Are you a US Citizen? If Yes, OK. If NO, do they have a Green Card? _____________________________________
- How much insurance are you seeking? $$ __________________________ Purpose:___________________________
_________________________________________________________________________________________________
Existing coverage: ________________________________________________________________________________ - Do you plan to do any foreign travel or have you traveled to any foreign countries recently? If so, where?
_________________________________________________________________
NOTES: ___________________________________________________________________________________________
____________________________________________________________________________________________________