Life Insurance Pre-qualification

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

First Name

Middle Name

Last Name

Date of Birth

Height

Weight

Phone Number

E-mail Address

Are text messages ok?

Yes

Clear selection

Have you ever been diagnosed by a medical professional or tested positive for Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?

Yes

Clear selection

Have you ever been diagnosed with, received treatment for, or been advised by a medical professional to seek treatment for any of the following?

Heart Conditions: Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Stent Placement, Valvular Heart Disease with Repair or Replacement, Cardiomyopathy, Congestive Heart Failure, Congenital Heart Disease, Pacemaker, Defibrillator, Stroke, Transient Ischemic Attack (TIA)/mini-stroke, abnormal heart rhythm, or Cerebral, Aortic or Thoracic Aneurysm

Lung Conditions: Chronic Lung Disease (except mild Asthma), including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Sarcoidosis, or Cystic Fibrosis

Neurological Conditions: Bipolar Depression, Schizophrenia, Alzheimer’s Disease, Dementia, Parkinson’s Disease, Sickle Cell Anemia, Lou Gehrig’s Disease (ALS), Muscular Dystrophy, Demyelinating Disease including Multiple Sclerosis, Huntington’s Disease, Hydrocephalus, Quadriplegia, Paraplegia, Down Syndrome, Autism, Intellectual Developmental Disorder, or any other disease of the central nervous system

Kidney, Pancreas, and Liver Conditions: Chronic Kidney Disease, end-stage Renal Disease with dialysis, Chronic Pancreatitis, or Liver Disease including Cirrhosis, Hepatitis B, or Hepatitis C

Cancer: Cancer, Leukemia, Melanoma, Lymphoma, or any other internal cancer (except basal cell or squamous cell skin cancer)

Autoimmune Conditions: Systemic Lupus or Scleroderma

Organ Transplant:

None of the Abve

Currently, or within the past 12 months, have you:

Required Assistance: Needed assistance from another person or device for bathing, dressing, eating, toileting, getting in and out of a chair or bed, or managing bowel or bladder problems

Received Specialized Care: Received or been advised to receive care in a nursing home, assisted living facility, adult day care facility, home health care services, hospice care, or are you currently confined to a hospital or other medical facility?

Used Medical Devices: Used a walker, wheelchair, electric scooter, oxygen (excluding use for sleep apnea), or catheter?

None of the Above

In the past 12 months, have you:

(a) Been Advised to Have a Procedure: Been advised by a medical professional to have surgery, diagnostic testing (other than routine screenings or those related to HIV/AIDS), treatment, or another procedure that has not been done?

(b) Received Treatment for Specific Symptoms: Received treatment for a chronic cough, unexplained weight loss greater than 10 pounds (other than due to diet or exercise), fatigue, or unexplained gastrointestinal bleeding?

None of the above

In the next 2 years, do you plan to engage in any of the following activities? Motorsports racing, boat racing, parachuting/skydiving, hang gliding, base jumping, rock or mountain climbing

Yes

Clear selection

In the past 10 years, have you:

Used alcohol to a degree that required treatment or been advised to limit or discontinue its use by a medical professional?

Used or been convicted of possession of unlawful drugs (other than marijuana) or used prescription drugs other than as prescribed?

Been convicted of or are currently awaiting trial for a felony?

None of the Above

In the past 5 years, have you:

Been convicted of driving under the influence of drugs or alcohol, reckless driving, or four or more moving violations?

Hospitalizations: Been hospitalized for high blood pressure or any mental or nervous disorder?

None of the Above

Have you ever been diagnosed with, received treatment for, or been advised by a medical professional to seek treatment for diabetes?

Yes

Clear selection

In the past 12 months, have you applied for or received disability, hospital, or medical benefits from any insurance company, government, military, employer, or other source (other than for maternity, fractures, spinal or back disorders, or joint replacement)?

Yes

Clear selection

In the past 5 years, have you been hospitalized, received treatment for, or been advised by a medical professional to seek treatment for any other health condition (other than for routine physical checkups, eye exams, employment exams, or FAA examinations)?

Yes

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms