Life Benefit Questionnaire

9%

Height & Weight
What is your current height (feet)?*
(ex. 5')
What is your current height (inches)?*
(ex. 9")
What is your current weight?*
Please round up to the nearest pound. (ex. 126.5 = 127)
Have you experienced a weight change of 10 pounds or more in the last 12 months?*
- Yes
- No
Pounds lost?
Pounds gained?
Reason for change?

Tobacco Use
Have you EVER used tobacco in any form, or smoking cessation products (such as e-cigarettes, nicorette, chantix, etc.)?*
- Yes
- No
Product(s) used?*
Frequency of use?*
Date of Last Use*
Date Format: MM slash DD slash YYYY

Health History
Have you EVER been diagnosed, received treatment, or consulted a health professional for any of the following? If YES, please check all that apply.*
- No, none of these apply to me.
- High Blood Pressure
- Chest Pain
- Heart Attack
- Heart Murmur
- Diabetes
- High Cholestrol
- Cancer, Tumor or Polyp
- Asthma or Bronchitis
- Emphysema
- Sleep Apnea
- Seizures
- Stroke or TIA
- Paralysis
- Multiple Sclerosis
- Parkinson's Disease
- Alzheimer's Disease
- Dementia or Memory Loss
- Colitis
- Cirrhosis
- Hepatitis
- Arthritis
- Lupus
- Anemia
- Depression or Anxiety
- Eating Disorder
If you checked any of the boxes above please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment.
Other than those indicated above, have you EVER had any disease or disorder of any of the following? If YES, please check ALL that apply and provide details below.*
- No, None of these Apply
- Heart
- Arteries or Veins
- Lungs or Respiratory System
- Gastrointestinal Digestive System
- Liver or Pancreas
- Kidney or Bladder
- Prostate
- Reproductive Organs
- Brain or Nervous System
- Blood
- Lymph Nodes
- Immune System
- Thyroid or Other Glands
- Eyes
- Ear, Nose or Throat
- Skin
- Muscles, Bones or Joints
- Emotional or Psychological Disorder
If you checked any of the boxes above please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment.

Other than indicated previously, in the past 5 years, have you had any illness, injury, surgery, physical exam, consultation or medical test (ex. laboratory tests, EKG, etc.), or been a patient in a hospital or other medical facility?*
- Yes
- No
If yes please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment.*

Are you currently receiving any treatment or taking any prescription or nonprescription medications or supplements?*
- Yes
- No
If yes please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment, and provide accurate spelling, dosage and reason for medication.*
Do you have any surgery, medical test, treatments or visits with a health professional scheduled in the next six months?*
- Yes
- No
If yes please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment.*
Have you ever been diagnosed with, or treated by a member of the medical profession, for Acquired Immune Deficiency Syndrome.*
- Yes
- No
If yes please provide a description with as much detail as possible that includes the diagnosis, date of diagnosis, treatment.*

Have you ever used cocaine, heroin, or other illicit drugs or controlled substances EXCEPT as prescribed by a health professional?*
- Yes
- No
If yes, provide the type of substance used, the initial date used, the frequency of use, and the date of last use.*
Have you ever sought, been advised to seek, or received counseling or treatment for the use of alcohol or drugs by a health professional or support group?*
- Yes
- No
If yes, please provide a description to include the diagnosis, date of diagnosis, treatment and doctor's name and/or facility where you were diagnosed. Also, provide the date of last use and if you are active with a support group currently.*

Family History
Does your father have any history of cancer, cardiac disease or diabetes prior to age 65?*
- Yes
- No
If yes, please detail the age he was diagnosed & type of cancer, cardiac disease or diabetes.*
If applicable, age of father's death?
If applicable, cause of father's death:
Does your mother have any history of cancer, cardiac disease or diabetes prior to age 65?*
- Yes
- No
If yes, please detail the age she was diagnosed & type of cancer, cardiac disease or diabetes.*
If applicable, age of mother's death?
If applicable, cause of mother's death:
Do(es) your sibling(s) have any history of cancer, cardiac disease or diabetes prior to age 65?*
- Yes
- No
If yes, please detail the age of diagnosis, and types of cancer, cardiac disease or diabetes.*
If applicable, list the ages and causes of sibling(s) death.

Personal History
Within the last five years, have you filed for bankruptcy, or had any judgments or liens filed against you?*
- Yes
- No
If yes, discharge date:*
Date Format: MM slash DD slash YYYY
Have you ever been convicted of a misdemeanor or felony?*
- Yes
- No
If yes, please provide details of charges and conviction.*
Are you currently receiving workers' compensation, social security or disability income?*
- Yes
- No
If yes, please provide the start date and reason.*

Travel History
Has your driver's license ever been suspended or revoked in the past 5 years?*
- Yes
- No
If yes, please provide details.*
Have you ever been convicted, or plead guilty or no contest to, reckless driving or driving under the influence of alcohol or drugs in the past 5 years?*
- Yes
- No
If yes, please provide the month and year of conviction.*
MM
DD
YYYY
In the past 5 years have you had 3 or more speeding tickets?*
- Yes
- No
If yes, please provide month and year of ticket and the mph over the speed limit you were going.*
Please select any activities you have participated in the last 3 years, or you plan to engage in in the future.*
- Aviation
- Ultra-Light Flying
- Hot-Air Ballooning
- Mountain, Rock, or Ice Climbing
- Motor Vehicle Racing or Boat Racing
- Scuba Diving
- Sky Diving
- I have not, and do not plan, to engage in any of these activities.
If you have, or plan to, engage in any of the above activities, please provide dates of engagement in the activities and details specific to the avocation including types, heights, speeds, depths, location and your future plans.
Are you instrument flight rated*
- Yes
- No
Number of hours flown in the past 12 months:
Current number of hours flown:
Number of flight hours contemplated in the next 12 months:
Do you plan to travel outside the United States in the future?*
- Yes
- No
Where?
When?
For how long?

Insurance History
Have you ever had life, health, or long term care declined, rated or issued other than you had applied for?*
- Yes
- No
If yes, please provide the dates and reasons the decline or rating:*