Life Benefit Questionnaire

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*
MM slash DD slash YYYY

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:*
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.*

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:*

Personal Information