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Health Questionnaire

Primary Insured health Questions
Full Legal Name*
This is your name if you are filling this out for yourself. If you are filling this out for a second or other applicant then use their name here.
Prefix First Middle Last Suffix
Height*
Weight*
Driver's License number:*
Driver's License issue state:*
Driver’s license expiration*
MM slash DD slash YYYY
Social security number*
How long have you had your business/been with your current employer*
How long have you been at your current home address*
What county is your home address in*
What is your state of birth
Who would you like as your beneficiary
Name of beneficiary*
Prefix First Middle Last Suffix
Beneficiary Relationship*
Beneficiary DOB
Month
Day
Year
Family History:
Age of Mother if living
Please enter a number less than or equal to 120.
Age of Mother at death
Please enter a number less than or equal to 120.
Mother's state of heath or cause of death
My Mother has / had
- Cancer
- Heart Problems
- Diabetes
If yes, please explain
Age of Father if living
Please enter a number less than or equal to 120.
Age of Father at death
Please enter a number less than or equal to 120.
Father's state of heath or cause of death
My Father has / had
- Cancer
- Heart Problems
- Diabetes
If yes, please explain
Age of all siblings if living
Age of all siblings at death
State of heath or cause of death for each sibling
My Siblings have / had
- Cancer
- Heart Problems
- Diabetes
If yes, please explain
Lifestyle Questions
Have you been convicted of a driving violation, driving under the influence of alcohol or drugs, or had your license suspended or revoked?*
- Yes
- No
If Yes, Please provide details:
Plead guilty to or been convicted of a felony or misdemeanor or do you have such charge currently pending against you?*
- Yes
- No
If Yes, Please provide details:
If Yes list the nature of the plea, conviction or charge, the date and State where the plea, conviction or charges occurred, whether time was served in prison and status of probation.
Has any company declined, postponed, rated or refused to reinstate insurance?*
- Yes
- No
If Yes, Please provide details:
Have you ever used narcotics, barbiturates, marijuana, amphetamines, hallucinogens, heroin, cocaine, or other habit forming drugs, except as prescribed by a physician?*
- Yes
- No
If Yes, Please provide details:
Have you ever received medical treatment or counseling for, or been advised by a physician to discontinue, the use of alcohol or prescribed or non-prescribed drugs?*
- Yes
- No
If Yes, Please provide details:
Have you ever Been a member of any self-help group such as Alcoholics Anonymous or Narcotics Anonymous?*
- Yes
- No
If Yes, Please provide details:
Have you participated in any vehicle racing, parachuting, hang gliding, scuba diving, ballooning, rock or mountain climbing or spelunking within the past two (2) years or is any such activity contemplated?*
- Yes
- No
Avocation Supplement.
Because you answered "Yes" you are required to complete an Avocation Supplement.

You will receive instructions about supplements after submitting this form.
Have you flown within the past two (2) years as a pilot, student pilot, crew member or had any flying duties, or is any such activity contemplated?*
- Yes
- No
Aviation Supplement
Because you answered "Yes" you are required to complete an Aviation Supplement.

You will receive instructions about supplements after submitting this form.
Do you contemplate travel or residence in a foreign country within the next 24 months?*
- Yes
- No
Foreign Travel Supplement
Because you answered "Yes" you are required to complete a Foreign Travel Supplement.

You will receive instructions about supplements after submitting this form.
Do you have any current or expected connection with the Armed Forces?*
- Yes
- No
Armed Forces Supplement
Because you answered "Yes" you are required to complete an Armed Forces Supplement.

You will receive instructions about supplements after submitting this form.
Have you ever used any nicotine and/or tobacco products?*
(including substitutes such as gum, patch, etc.)
- Yes
- No
When?
- Present
- Former
Type of nicotine or tobacco used:
When did you quit using all forms of nicotine (including substitutes) or tobacco?

Day
Month
Year
Physician Information:
Personal Physician
If none check this box.
- None
Name of personal physicians
Physician Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date and reason last consulted
List any prescription medications taken daily
List dosage, frequency, reason prescribed, and the doctor who prescribed.

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