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Preferred Risk Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1. PLEASE DETAIL THE CLIENT'S MEDICAL HISTORY:
FATHER'S AGE IF LIVING
 
OR AT THE TIME OF DEATH AND CAUSE OF


MOTHER'S AGE IF LIVING
 
OR AT THE TIME OF DEATH AND CAUSE OF


SIBLING'S AGE IF LIVING
 
OR AT THE TIME OF DEATH AND CAUSE OF

2. DETAIL THE CLIENT'S MEDICAL HISTORY (CHECK ANY APPLICABLE)
CANCER HISTORY 
HEART HISTORY / CONDITION
DIABETES HISTORY 
ALCOHOL OR DRUG ABUSE HISTORY
HIGH BLOOD PRESSURE,
    IF YES, PLEASE DETAIL:

    CURRENT READING

    HDL READING OR RATIO

    TYPE OF TREATMENT


ELEVATED CHOLESTEROL HISTORY, IF YES, PLEASE DETAIL:
    CURRENT READING

    HDL READING OR RATIO

    TYPE OF TREATMENT


ELECTROCARDIOGRAM (EKG), IF TAKEN WITHIN THE LAST YEAR: RESULTS:
NORMAL, OTHER

STRESS EKG OR THALLIUM, IF TAKEN WITHIN PAST LAST YEAR: RESULTS:
NORMAL, OTHER

SIGMOIDOSCOPY IF TAKEN WITHIN PAST YEAR, DETAIL:
LAST YEAR: RESULTS:
NORMAL, OTHER

PROSTATE EXAM, IF TAKEN WITHIN THE PAST YEAR, 
LAST YEAR: RESULTS:
NORMAL, OTHER

MAMMOGRAM, IF TAKEN WITHIN THE PAST YEAR, 
LAST YEAR: RESULTS:
NORMAL, OTHER

3. HAS THE CLIENT HAD A STANDARD CHECKUP WITHIN THE LAST YEAR?
IF YES, DETAIL DATE AND RESULTS:

4. CLIENT'S MARITAL STATUS:

5. DOES THE CLIENT CURRENTLY TAKE ANY MEDICATION? WHAT TREATMENT IS CURRENTLY BEING PRESCRIBED?
IF YES, DETAIL DATE AND RESULTS:

6. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

7. DOES THE CLIENT TAKE VITAMINS?
IF YES, PLEASE DETAIL

8. HAS THE CLIENT RECEIVED ANY DRIVING VIOLATIONS DURING THE PAST THREE YEARS?
IF YES, PLEASE DETAIL DATE & TYPE

9. DOES THE CLIENT PARTICIPATE IN AVIATION / AVOCATION ACTIVITIES?
IF YES, PLEASE DETAIL DATE & TYPE

10. CLIENT'S OCCUPATION

11. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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