|
Name of the Person to be insured |
First
*
*
req'd
|
Last
* |
|
| Gender |
* |
|
|
| Home
Zip Code |
* |
|
|
| Birth Date |
*
Example: 04/20/1956 |
|
|
|
Height and Weight |
*
feet
*
inches
|
* pounds
|
|
| Marital Status |
* |
|
|
| Do you have Children? |
* |
|
|
|
Occupation |
*
|
|
|
|
Annual
Income |
*
|
|
|
| Where does this person currently live? |
* |
|
|
|
DOES OR HAS ANY PERSON TO BE INSURED: |
|
| Require the assistance or supervision of
another person or any device for bathing, dressing, eating, toileting,
getting in or out of bed or chair; have an inability to control bowel or
bladder functions; or need or use a wheelchair, walking aid of any medical
device such as a walker, or oxygen equipment |
|
Been advised to enter or been confined to a nursing home,
long term care facility, hospital, received home health care, or used an
adult day care center in the past 212 months? |
|
|
Been advised to have surgery but have not yet had such surgery, or is
currently receiving physical therapy, or had a surgical procedure from which
such person has not yet recovered? |
|
Been diagnosed, treated, received medical advice or been hospitalized for
Alzheimer's Disease, dementia, senility, memory loss, organic brain
syndrome, Parkinson's Disease or systemic lupus, Multiple Sclerosis,
Muscular Dystrophy. ALS (Lou Gehrig Disease), or stroke in the past 5 years? |
|
| Been diagnosed, treated, received medical advice or been
hospitalized in the past 2 years for:
a. Kidney dialysis, transient,
ischemic attack (TIA), congestive heart failure, cadiomyopathy, diabetes
requiring insulin, or amputation caused by circulatory disease or diabetes,
internal cancer or malignant melanoma?
|
|
b. Osteoporosis with fractures, rheumatoid arthritis, joint replacement,
Chronic Obstructive Lung Disease or emphysema? |
|
| Been treated for or been diagnosed by a medical
professional as having Acquired Immune Deficiency Syndrome (AIDS), AIDS
Related Complex (ARC), or Human Immunodeficiency Virus (HIV) infection?
These conditions are defined as having signs and symptoms which may include
generalized Lymphadenopathy (swollen Lymph nodes), loss of appetite, weight
loss, fever, oral thrush, skin rashes, unexplained infections, depression or
other psychoneurotic disorders with no known causes. |
|
In the past five years , has any person to be insured been diagnosed,
treated or received medical advice for heart disease, respiratory disease,
cerebrovascular disease, internal cancer or malignant melanoma, diabetes,
osteoarthritis or depression? |
|
| |
|
|
|
| Has this person ever smoked? |
|
|
Has this person
been treated for any condition other than minor colds/flu in the past
12 months? |
|
|
|
|
Currently taking any non-voluntary prescription medicine |
|
|
Diagnosed with High Blood Pressure |
|
|
|
|
Currently being treated by a physician |
|
|
Diagnosed with Heart Attack or Stroke |
|
|
|
|
Diagnosed with Asthma |
|
|
Prescribed medicine for depression |
|
|
|
|
Diagnosed with Diabetes |
|
|
Any other Major Illness or Condition |
|
|
|
|
Diagnosed with Cancer |
|
Is any person to be insured currently eligible for Medicaid or on early
Medicare (Prior to age 65) |
|
| |
|
|
|
| Hospitalized in the past 5 years (other than for
pregnancy)? |
|
If "Yes" answered to any of the above, give a brief description:
|
|
| |
|
|
|
|
List all medications any person to be insured is
currently taking or has taken in the past 12 months? Name
Medication
Dosage
Reason
How long?
|
| |
Last life insurance applied for and results. |
|
|
|
Last
Company
|
Date
|
Result:
Rated Table
|
|
| |
|
|
|
|
How to get in touch with you |
| Your
Name |
First
Last
*
*
|
|
|
|
Street Address |
*
|
|
|
|
Apartment/Room/Suite |
|
|
|
|
City |
* |
|
|
|
Resident
State |
*
NC Only |
|
|
| Zip Code |
*
|
|
|
|
Phones
(with area
code): |
Contact Phone
Other
*
(123-456-7890) |
Best Time to Call
*
|
|
|
Email
Address:
|
* |
(We will not share your email address) |
|
| Please tell us how you heard about this
website: |
|
|
|
| |
|
|
|
|
|
|
|
|