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Life Benefit Questionnaire
Step 1 of 11
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Personal Information
Your Name
*
First
Last
Advisor Name
*
First
Last
Birthday
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
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:
*