PinnacleQuote PreQualification For Rate Class
Health/Lifestyle Questionnaire to Determine Rate Qualification
Email address *
Date Of Birth *
Have you ever smoked cigarettes?
Have you ever used OTHER NICOTINE products?
In the last 10 years have you used Marijuana for medical or recreational purposes?
How Tall are you?
What do you weigh?
Your answer
Have you lost more than 10 pounds in the last 12 months?
Any treatment for high Blood Pressure?
Any treatment for elevated Cholesterol?
Heart Problems or Irregular Heart Beat?
Past history of Stroke, Mini Stroke, Blood Clots?
History of Diabetes or Elevated Blood Sugar?
Last A1C reading (if known)
Any Treatment for Diabetes?
Any form of Cancer or Tumors?
Any issues with Asthma or Respiratory Ailments
History of Sleep Apnea?
Past issues with Anxiety or Depression
History of Alcohol or Drug abuse
Any issues with Liver or Kidney's?
Any Medications or treatments that you haven't told me about?
Your answer
Any immediate family deaths before age 65?
Driving History, Last 5 years any moving violations? (Ex: Speeding/Stop signs)
Any Dui's or Reckless Driving?
Own a plane? Pilots License?
Any Scuba Diving or any other Hazardous Sports?
What state were you born in?
Your answer
US Citizen?
Next 2 years do you have any intention to live outside the US?
Are you active duty in the Military?
Life Insurance Ever Been Rated, Canceled, Postponed or Declined?
Any Life Insurance applications Pending with any other Carrier?
Have you ever declare Bankruptcy?
Have you ever been convicted of a Misdemeanor?
Have you ever been convicted or a Felony?
A copy of your responses will be emailed to the address you provided.
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