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Birth Date
Gender Male Female
Ever used tobacco or related substances? Yes No
State
Face Amount
Product Type
Health Risk
Physique
 
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Extended Information: Quotation Questionaire

 
Please Note: The Qualification Analysis is intended to fine tune the comparisons and quotations, and to better reflect what you may actually qualify for. It should be noted, however, that it is for guideline purposes only. The underwriting criteria and practices of each insurer and the wordings of each respective policy contract govern. E.&.O.E.
What is your blood pressure?
Have you ever received treatment or medication for high blood pressure?
What are your cholesterol figures?
Have you ever received treatment or medication for cholesterol?
Do you have any history of or been treated for alcohol abuse?
Do you have any history of or been treated for drug or substance abuse?
Have you ever been convicted of a minor moving violation? Yes No
If Yes then when:  
Have you ever been convicted of a major moving violation? Yes No
If Yes then when:  
If you have ever been convicted of a major moving violation, what was the nature of the violation?
Have any immediate family members (parents, brothers or sisters) suffered from heart disease or heart attack? Yes No   If Yes then when
Parent(s)
Sibling(s)
Have any immediate family members (parents, brothers or sisters) suffered from Cerebrovascular Disease? Yes No   If Yes then when
Parent(s)
Sibling(s)
Have any immediate family members (parents, brothers or sisters) suffered from Cancer? Yes No   If Yes then when
Parent(s)
Sibling(s)
Have any immediate family members (parents, brothers or sisters) suffered from Diabetes? Yes No   If Yes then when
Parent(s)
Sibling(s)
Have any immediate family members (parents, brothers or sisters) suffered from other critical illness? Yes No   If Yes then when
Parent(s)
Sibling(s)
 
 
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