Quote Request: Preliminary Health & Family History Information

Advisor Information

Financial Advisor Name *

Financial Advisor Company

Proposed Insured

First Name *

Middle Name

Last Name *

Preferred Name / Nickname

Date of Birth (MM/DD/YYYY) *

Are you a U.S. Citizen? *

Yes No Unknown Unanswered

Immigration Status *

Permanent Resident/Green Card Holder Visa Holder

Country of Birth *

Date of Entry *

Visa/Green Card Type *

Visa/Green Card Expiration Date *

Contact Information

Preferred Contact Number *

Email Address *

Current Address

Address

Address 2 (Apt, Suite, etc...)

City *

Zip Code

Household Information

Marital Status *

Number of Children *

Ages of Children

Occupation

Are you currently employed? *

Yes No Unknown Unanswered

Occupation *

Annual Earned Income ($) *

Please select: *

Stay at home parent Retired Other

Please explain *

Lifestyle Details

In the last five years, have you used tobacco in any form including cigars, cigarettes, pipe, chew, or nicotine products such as nicotine patch, nicotine gum, or e-cigarettes / vapor? *

Yes No Unknown Unanswered

Please list each tobacco/nicotine type: *

Tobacco/Nicotine Type 1

Amount/Frequency *

Example: 1 pack daily

Date Last Used *

Add Tobacco/Nicotine Type

Have you used marijuana in the last 5 years? *

Yes No Unknown Unanswered

Please describe details including

Frequency (# per week, month or year)
Date last used
How it is used (smoked, ingested, edibles, vape, etc.)
Recreational or medical use
- If medical use, do you have a prescription and what is the diagnosis?

Any/all information helps us find the best rates *

Do you consume alcohol? *

Yes No Unknown Unanswered

Type of Alcohol *

How Much? *

How often? *

Are you, or do you intend to become, a member of the Armed Forces, including the Reserves, or on alert? *

Yes No Unknown Unanswered

If yes, please explain. *

Are you planning to reside or travel outside the United States in the next 2 years? *

Yes No Unknown Unanswered

Please list planned cities, countries, purpose, dates, duration, etc... *

Have you ever been charged with a DUI/DWI, reckless driving, or had your driver’s license revoked or suspended? *

Yes No Unknown Unanswered

Please provide details such as violation type, arrest date, conviction date and any loss of license/probation/recommended counseling: *

Have you had any other motor vehicle/moving violations in the past 5 years? *

Yes No Unknown Unanswered

Please provide description (such as: speeding, accident, red light running, etc...) and approximate month/year of any violations: *

Health Details

Weight (lbs) *

Gender *

Male Female

Are you currently pregnant? *

Yes No Unknown Unanswered

What's your approximate due date? *

How much weight have you gained so far? *

Are you currently undergoing IVF? *

Yes No Unknown Unanswered

Please provide details including treatments, procedures and dates *

Even if not currently pregnant, have you had a history of gestational diabetes, complications or a history of multiple births with any pregnancies? *

Have you had any weight loss or gain of more than 10 lbs. in the last year? *

Yes No Unknown Unanswered

Please indicate amount of weight gain or loss, and reason: *

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

High blood pressure? *

Yes No Unknown Unanswered

Please provide date of diagnosis, medications (name, dosage, and frequency), last date of treatment (if applicable), & last reading/test result *

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

High cholesterol or high triglycerides? *

Yes No Unknown Unanswered

Please provide: Specific condition/diagnosis, date of diagnosis, any medications (name, dosage and frequency), last date of treatment (if applicable), and last reading/test result *

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Heart attack or coronary artery disease? *

Yes No Unknown Unanswered