Preliminary Inquiry Client InformationName of Insured :* First Last Date of Birth* Date Format: MM slash DD slash YYYY State of Residence*Gender* Male Female Height*Weight*Tobacco Use* Yes No Has client used any form of tobacco in the last 3 years?Please state type(s) of tobacco used, frequency and amount of use, when use began and/or how long since quitting*U.S. Citizen* Yes No Resident StatusPlease provide details of residency (type of Visa, Green Card, etc) Country of Citizenship and how long in U.S.Employed or Disabled?*Annual Income*Coverage InformationFace Amount*Policy Type* Term Term w ROP Universal Life Guaranteed UL Whole Life Premium Mode* Annual Semi Annual Quarterly Monthly Single Premium Other Term Duration (# of years)Total Insurance Currently Inforce*Indicate "none" if no insurance inforce If this policy will replace any existing coverage, please indicate below & include 1035 Exchange amount, if anyHas Client Ever Been Declined for Insurance Coverage?* Yes No Give Date & Reason for Decline*Medical Provider InformationDo You Have a Primary Care Physician?* Yes No Date Last Consulted* Date Format: MM slash DD slash YYYY Does Client See Any Specialist?* Yes No Type of Specialist, Reason for Consultation, Treatments Prescribed*Health HistoryWhen providing details, please include date of diagnosis & provider who diagnosed and what treatments have or are currently being doneCardiovascular Conditions* Heart Disease Angina Stroke High Blood Pressure None Please check all that applyDetails of Cardiovascular Condition(s)*Cancer History* Yes No Type, date of diagnosis, stage of cancer, grade, type of treatment(s), outcome of treatment, date and outcome of last scan. Date of any currently scheduled scans.*Diabetes* Type I Type II None Age at Diagnosis*Current A1-C Level*Current Treatments for Diabetes*Substance Use* Alcohol Marijuana Recreational "Street" Drugs Any Drug Not Prescribed by a Physician None Check all that apply to client's current use or history of useDetails of Substance Use/Abuse*Please state type(s) substance used, frequency and amount of use, when use began and/or how long since quitting. Indicate if client has been advised to have or has had treatment for ABUSE of any substance, including treatment dates List of Medications or Other Conditions Not Listed Above*Please list all medications that are currently being prescribed, including the dosage information. Please include details of other diagnosis not covered above (or enter none)General QuestionsBankruptcy (past 7 years)* Yes No Details of BanruptcyPlease indicate type of bankrutcy, causation, date of filing, date of dischargeDriving Record* DWI/DUI Speeding Violations Traffic Violations None Check all that applyDetails of Driving Record*List dates of violations and/or convictions Private Aviation Yes No If "yes", a seperate questionnaire will be needed in order to collect full details Hazardous Avocations Scuba Diving Hang Gliding Rock Climbing Auto Racing Other Check all that apply. A seperate questionnaire will be needed to collect details on any avocation(s). Travel or Residence Outside of U.S. or Canada* Yes No Details of Foreign TravelProvide regions or destinations visited or resided, dates visited or resided and frequency /dates of future travel. Agent InformationName* First Last Email* Agent Is Licensed In: Resident State of Insured Resident State of Policy Owner (if other than insured) Trust State (if a Trust is Owner or Beneficiary) Print & Sign Health Authorization Form to FollowWhen you click "Submit" below, you will be re-directed to the health information authorization form. Please provide a copy to your client and keep a signed copy on file.