| Agent Name * |
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| Agent Phone * |
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| E-mail Address: * |
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| Agent Fax |
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| Clients Date of Birth * |
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| Clients Gender * | Male
Female |
| What is the desired face amount? * |
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| What type of coverage is desired? (Term 10, 15, etc / Perm UL, VUL, SUL, etc) * |
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| Clients Height * |
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| Clients Weight * |
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| Does the clients chest measurement exceed their waste measurement? |
Yes
No |
| Has the client ever used any of the following tobacco products: cigarettes, cigars, pipe, chewing tobacco, nicotine gum, nicotine patch, or any other tobacco products? * |
Yes
No |
| Have any of the clients family members (biological) had an occurence of the following conditions: cardiovascular disease, cerebrovascular disease (stroke), diabetes, or cancer? Please select all that apply. |
None
Mother
Father
Sister
Brother |
| Has the client ever been treated or medicated for cholesterol? * |
Yes
No |
| What is the clients total cholesterol? |
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| Does the client know their HDL cholesterol? If yes please provide. |
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| Does the client know their LDL cholesterol? If yes please provide. |
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| What is the clients cholesterol ratio? |
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| Had the client ever been treated or medicated for blood pressure? |
Yes
No |
| Is the client currently being treated for blood pressure? |
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| What is the clients pulse pressure? |
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| What is the clients systolic blood pressure? |
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| What is the clients systolic blood pressure AVERAGE for the last 12 months? |
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| What is the clients AVERAGE systolic pressure for the last 24 months? |
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| What is the clients diastolic blood pressure? |
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| What is the clients AVERAGE diastolic pressure for the last 12 months? |
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| What is the clients AVERAGE diastolic pressure for the last 24 months? |
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| Has the client ever been convicted of a DWI, DUI, reckless driving, moving violation, license revocation or suspension? If yes please indicate which. |
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| Has the client ever participated in any hazardous avocations? (Aviation, climbing, gliding, motor-sport, scuba, etc |
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| Does the client plan to travel outside the US or Canada? |
Yes
No |
| Has the client ever been treated for or suffered from any of the following: * | Alzheimers/Dementia/Cognitive Impairment
Anxiety
General Arthritis
Rheumatoid Arthritis
Astma
Atrial Fibrillation
Breast Cancer
Colon Cancer
Leukemia
Lung Cancer
Lymphoma (Hodgkins)
Lymphoma (Non-Hodgkins)
Ovarian Cancer
Prostate Cancer
Skin Cancer
Other Cancer
COPD
Coronary Artery Disease
Cerebrovascular Disease / TIA
Crohns Disease (Type I)
Chohns Disease (Type II)
Drug Abuse
Epilepsy
Heart Murmer / Valve Disease
Hepatitis A
Hepatitis B
Hepatitis C
Irregular Heartbeat / Palpitations
Kidney Diseas
Lupus
Cirrhosis
Elevated Liver Functions (LFT)
Multiple Sclerosis
Parkinsons Disease
Peripheral Vascular Disease
Sleep Apnea
Stroke
Weight Reduction Surgery |
| List all other details, considerations, APS summaries or quote related information not previously provided. |
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